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COPYRIGHT DEPOSIT 



SURGICAL 



PATHOLOGY 



AND 



THERAPEUTICS 



BY 



JOHN COLLINS WARREN, M. D., LL.D., 

PROFESSOR OF SURGERY IN HARVARD UNIVERSITY ; SURGEON TO THE 
MASSACHUSETTS GENERAL HOSPITAL. 



ILLUSTRATED 



SECOND EDITION 



APPENDIX 

CONTAINING AN ENUMERATION OF THE SCIENTIFIC AIDS TO SURGICAL 

DIAGNOSIS, TOGETHER WITH A SERIES OF SECTIONS 

ON REGIONAL BACTERIOLOGY 



PHILADELPHIA 

W. B. SAUNDERS 

925 WALNUT STREET 
1900 



TWO COPIES RECEIVED, 

Ubr*ry of CongrM% 
Office of the 

ff" ? 9 1900 

ftegltttr of Copyrights 



<^t 






fi\t 



54282 

Copyright, 1900, by 
W. B. SAUNDERS 



SfcCOND GOP*- 



WESTCOTT &. THOMSON, PRESS OF 

ELECTROTYPEHS, PHILADA. W. B. SAUNDERS, PHILADA. 



Felix qvi potvit rervm cognoscere cavsas 
Atqve metvs omnes et inexorabile fatvm 
svbiecit pedibvs strepitvmqve acherontis avari. 

Virgil, Georg. II. 490. 



PREFACE TO THE SECOND EDITION. 



In the second edition of this book the attempt has been made 
to embody all the important changes in a new Appendix which 
replaces the old one and the chapter on Antiseptic Surgery. 

In this new chapter the author has aimed to present in as prac- 
tical a manner as possible the resources of surgical pathology. In 
addition to an enumeration of the scientific aids to surgical diag- 
nosis, there is presented a series of sections on what may be termed 
regional bacteriology, in which are given a description of not only 
the flora of the affected part, but also the general principles of 
treating the affections which they produce, based upon the latest 
views of the best authorities. It is hoped in this way to make 
the book of value to specialists in many of the departments of 
medicine. 

The author begs to acknowledge his indebtedness to Drs. A. K. 
Stone, R. B. Greenough, J. L- Goodale, H. A. Lothrop, Farrar 
Cobb, Mark Richardson, F. B. Lund, and Mr. Walter Dodd in 
the preparation of this edition. 

58 Beacon Street, Boston, 
January, 1 900. 



PREFACE 



The scientific portion of a surgical education was formerly re- 
garded as something apart and ornamental, but it has now become 
an eminently practical feature of the student's curriculum. 

No young practitioner can be regarded as thoroughly equipped 
for surgical work who is not both a good pathologist and an expert 
bacteriologist. The confidence born of a knowledge of Pathology 
and Bacteriology enables him to assume grave responsibilities and 
to grapple successfully with the most complicated problems. It is 
from men thus equipped that we have a right to hope that the 
future masters of surgery are to be evolved. 

An attempt is therefore made in this book to associate pathologi- 
cal conditions as closely as possible with the symptoms and treatment 
of surgical diseases, and to impress upon the student the value of 
these lines of study as a firm foundation for good clinical work. 

It is the Author's hope that the following pages will present to a 
large number of practising physicians, in a readable form, many 
subjects that received but little attention when they graduated. 

The illustrations by Mr. William J. Kaula are, with one or two 
exceptions, original. The drawings of microscopical sections are 
taken from specimens prepared for the purpose, and are intended 
to illustrate as closely as possible the results of modern micro- 
scopical technique. 

The Author takes this opportunity to acknowledge his indebted- 
ness to Dr. Arthur K. Stone for valuable assistance, and to express 
his appreciation of the courtesy extended to him by many of his 
colleagues during his labors. 



CONTENTS. 



• ?AGE 

I. Bacteriology 17 

II. Surgical Bacteria 43 

III. Hyperemia 79 

IV. Simple Inflammation 92 

1. The Process 92 

V. Simple Inflammation {continued} no 

2. Symptoms and Causes of Inflammation no 

3. Varieties and Treatment of Inflammation 125 

VI. Infective Inflammation 135 

1. Etiology 135 

VII. Infective Inflammation {continued) 155 

2. Suppuration 155 

3; Abscess 161 

4. Ulcer 182 

5. Fistulae 190 

VIII. Infective Inflammation {continued) 193 

6. Acute Osteomyelitis , 193 

IX. The Process of Repair 218 

X. Gangrene 256 

XI. Shock 2^^ 

XII. Fever 301 

XIII. Surgical Fevers 316 

XIV. Septicemia 334 

XV. Pyemia 356 

XVI. Erysipelas 381 

XVII. Hospital Gangrene 409 

XVIII. Tetanus . . . 435 

XIX. Hydrophobia ....:* 1 ....... . 453 

7 



8 CONTENTS. 



PAGE 



XX. Actinomycosis 469 

XXI. Anthrax . 477 

XXII. Glanders 485 

XXIII. Snake-bite 495 

XXIV. Tuberculosis 504 

XXV. Surgical Tuberculosis oe Joints . 529 

XXVI. Tuberculosis oe the Soft Parts 558 

1. Tuberculosis of the Skin 558 

2. Tuberculosis of the Mucous Membranes 565 

3. Tubercular Peritonitis 569 

4. Tuberculosis of the Genito-urinary Organs 573 

5. Tuberculosis of the Mamma 583 

6. Tuberculosis of the Lymphatic Glands . 585 

7. Tuberculosis of the Tendon-sheaths 589 

8. Scrofula 593 

XXVII. Diseases of Bone 597 

1. Osteomalacia .... 597 

2. Rickets . . 603 

3. Osteoporosis 609 

4. Hyperplasia of Bone 612 

5. Phosphorus-necrosis 617 

6. Arthritis Deformans 620 

7. Spinal Arthropathy 624 

8. Ankylosis 625 

9. Periostitis < 628 

XXVIII. Tumors 633 

XXIX. Carcinoma 638 

1. Carcinoma of the Skin 648 

2. Carcinoma of the Breast 662 

3. Carcinoma of the Uterus 672 

4. Carcinoma of the Tongue 677 

5. Carcinoma of the CEsophagus 684 

6. Carcinoma of the Larynx . . 686 

7. Carcinoma of the Stomach 688 

8. Carcinoma of the Intestines 689 

9. Carcinoma of the Rectum 690 

10. Carcinoma of the Bladder 694 

11. Carcinoma of the Kidney 696 

12. Carcinoma of the Testicle 698 



CONTENTS. 9 



PAGE 



XXX. Sarcoma 702 

1. Sarcoma of Skin 709 

2. Sarcoma of Bone 712 

3. Sarcoma of Kidney 718 

4. Sarcoma of Bladder 719 

5 . Sarcoma of Uterus 720 

6. Sarcoma of Testis 721 

7. Sarcoma of Breast 723 

8. Sarcoma of the Air-passages . , 725 

9. Sarcoma of the Digestive Tract 729 

10. Sarcoma of Brain , « 729 

11. Lymphosarcoma 730 

XXXI. Benign Tumors 737 

1. Adenoma 7^7 

2. Goitre 743 

3. Cystoma 748 

4. Papilloma 751 

5. Fibroma 753 

6. Myxoma 758 

7. Lipoma 760 

8. Glioma 763 

9. Chondroma 765 

10. Osteoma 769 

11. Neuroma 771 

12. Myoma 774 

13. Angioma . . . . 777 

14. Lymphangioma 781 



APPENDIX. 

I. Scientific Aids to Surgical Diagnosis 785 

Blood Examination 786 

Bacteriological Examinations ■ 788 

Urinary Conditions 790 

Spinal Puncture 794 

Feces 795 

Microscopical Examination of Pieces of Tissue suspected of 

being of Malignant Growth 795 

Rontgen Rays in Surgery 796 



io APPENDIX. 

PAGE 

II. Surgical Bacteriology of the Skin 800 

Avoidance of Wound-infection 801 

Treatment of Wounds 807 

III. Bacteriology of the Mouth and Pharynx, Eye, Ear, and 

Nose 812 

The Mouth and Pharynx 812 

Surgical Preparation of the Mouth for Operation . . . .813 

Pathogenic Bacteria of the Mouth . 814 

The Antiseptics of Tooth-filling . . 815 

Diagnosis of Acute Infectious Inflammations of the Mouth 816 

The Eye 816 

The Ear 819 

The Nose 820 

IV. Bacteriology of the Genito-Urinary System 822 

Predisposing Conditions ; Role Played by Bacteria in the 

Causation of Cystitis 823 

Bacterial Invasion 824 

Reaction of the Urine 824 

Bacteria in the Vicinity of the Meatus Urinarius and in the 

Male Urethra 825 

Bacteria of Cystitis 826 

Routes of Invasion of the Genito-Urinary System by Micro- 
organisms 828 

External Genitals and Urethra 828 

Bladder 828 

Kidney 829 

Vulva and Vagina 831 

Rectum and Anal Canal 831 

Local Applications 832 

V. Bacteriology of Peritonitis 834 

VI. Bacteriology of the Gall-Bladder 842 

VII. Sero-therapy in Tetanus, Tuberculosis, and Syphilis . . . 846 

Tetanus 846 

The Antistreptococcus Serum 848 

Surgical Tuberculosis 849 

Syphilis 850 



LIST OF ILLUSTRATIONS. 



FIG. PAGE 

i. Arnold Sterilizer » 32 

2. Potato Culture 33 

3. Method of Filling Test-tubes with Nutrient Material 35 

4. Petri Dish with Colonies 36 

5. Bacteriological Syringe (H. C. Ernst) 40 

6. Staphylococcus P3'ogenes Aureus (Colored) 43 

7. Staphylococcus Pyogenes Albus (Colored) 43 

8. Streptococcus Pyogenes {Colored) 45 

9. Streptococcus Pyogenes (culture) (Colored) 46 

10. Bacillus P}-ocyaneus (Colored) 47 

11. Bacillus Coli Communis (Colored) 49 

12. Gonococci (Colored) 51 

13. Bacillus Tetani (Colored) 54 

14. Hydrogen Jar for Anaerobic Cultures 55 

15. Tuberculous Sputum (Colored) . 58 

16. Tuberculous Urine (Colored) 58 

17. Bacillus of Tuberculosis on Glycerin- Agar (Colored) 60 

18. Bacillus Mallei (Colored) 62 

19. Bacillus of Malignant CEdema ( Colored) 68 

20. Bacillus Anthracis (Colored) 71 

21. Section of Kidney from an Animal dead of Anthrax (Colored) ... jt, 

22. Section of Tumor of a Calf, showing Actinomyces (Colored) ... yy 

23. Blood-vessel, showing Diapedesis of Leucocytes 93 

24. Leucaemic Blood, showing various forms of Leucocytes (Colored) . 99 

25. Amceboid Movements of a Leucocyte 101 

26. Karyokinesis in the Cells of a Sarcoma (Colored) 105 

27. Metastatic Abscess of Kidney (Colored) 156 

28. Portion of Wall of Lung Abscess, natural injection (Colored) . . 157 

29. Pus-cells with Staphylococci 159 

30. Pus-cells treated with Acetic Acid, and Crenated Red Blood-cor- 

puscles 159 

31. Sterilized Test-tube and Swab for Collecting Pus and Fluids for 

Bacteriological Examination 160 

32. Diagram of Tendon-sheaths of the Hand (Tillaux) 169 

33. Columna Adiposa 176 

11 



12 LIST OF ILLUSTRATIONS. 

FIG. PAGE 

34. Infiltration of Columna Adiposa and Subcutaneous Tissue with Pus 

in Carbuncle 178 

35. Diagram of a Carbuncle 178 

36. Ulcer of Leg [Colored) 183 

ZJ. Point of Origin of Suppuration in Osteorrryelitis 197 

38. Extension of Suppuration in Osteomyelitis 199 

39. Necrosis of the Shaft and Periosteal Formation of Bone 199 

40. Separation of Sequestrum and Formation of Involucrum 201 

41. Unhealed Abscess-cavity, with Eburnation of Bony Tissue .... 201 

42. Necrosis of Femur, the result of Acute Osteomyelitis (Colored) . . 207 

43. Healing of Blood-clot, and Senn's Bone-chips 216 

44. Healing hy Second Intention (Colored) 226 

45. Vascular Spaces with Tissue filled with Leucocytes 227 

46. Detail Study from a Deep Layer of Granulation Tissue, showing a 

vessel with epithelioid cells and spindle-cell growth 228 

47. Development of Blood-vessel in Mesentery of an Embrj-o 230 

48. Development of Blood-vessel in Mesentery of an Embryo : forma- 

tion of vascular loops = 231 

49. Granulations compressing Blood-clot; injected specimen (Colored) . 232 

50. Healing of Tendon : callus formation with absorption of blood-clot 233 

51. Detail Stud}* of the End of the Divided Tendon (Colored) .... 234 

52. Repair of Muscular Fibre (Colored) . . 237 

53. Changes seen in the Repair of a Nerve after Division (Colored) . -. . 239 

54. Experimental Fracture (Dog) at the end of the first week, showing 

blood-clot and detached fragment of bone (Colored) 244 

55. Experimental Fracture (Dog) after forty-six days : ossification of 

callus (Colored) 245 

56. Ossification of Osteoid Substance in Callus of a Dog (Colored) . . 247 

57. Experimental Callus of a Dog (Colored) 248 

58. Detail Study of Three-weeks' Callus, showing osteoblasts forming 

new bone (Colored) , . 248 

59. Carotid Artery of Horse two weeks after ligature (Colored) .... 251 

60. Carotid Artery of Horse two months after ligature (Colored) . . . 252 

61. Femoral Artery of Man three months after ligature (Colored) . . . 253 

62. Tibial Artery from a case of Senile Gangrene of the Foot (Colored) . 258 

63. Gangrene of the Toes from Frost-bite (Colored) 269 

64. Ganglion-cells from the Cord of a Cat ; stimulated and resting-cells 286 

65. Traumatic Fever (chart) 318 

66. Aseptic Fever due to the absorption of blood-clot (chart) 320 

67. Infiltration of Muscular Tissue with Streptococci in a case of Septi- 

caemia of Man (Colored) 340 



LIST OF ILLUSTRATIONS. 13 

FIG. PAGE 

68. Sapraemia (chart) 345 

69. Septicaemia (chart) 346 

70. Capillary Embolus of Streptococci in a Sarcoma {Colored) .... 350 

71. Infiltration of Vessel-wall in Sarcoma {Colored) 351 

72. Thrombus of Femoral Vein {Colored') 362 

jt,. Pyaemia (chart) 368 

74. Traumatic Fever followed by Erysipelas in a case of Lithotomy 

(chart) 391 

75. Extravasation or " Miliary Abscess " in the cervical cord in a case 

of hydrophobia [Colored) 463 

76. Submiliary Tubercle, showing giant - and epithelioid cells 506 

jj. Tubercular Nodule of the Head of the Tibia {Colored) 516 

78. Tubercular Abscess-cavity, being the point of origin of disease of 

the hip-joint {Colored) 517 

79. Deformity from Absorption of Phalanx due to tubercular disease 

[Colored) 522 

80. Angular Deformity from Pott's Disease {Colored) 524 

81. Tuberculosis of the End of the Humerus, showing caries of the 

articular surface and osteophytes due to inflammation of the peri- 
osteum [Colored) 533 

82. Tuberculosis of Tendon-sheaths or Palmar Bursal Tumor {Colored) 592 

83. Trabecula of Bone in a case of Osteomalacia — on the left osteoclasts, 

and on the right osteoblasts {Colored) 597 

84. Section of Femur in a case of Osteomalacia : below is the medulla 

rich in cells, and above, the periosteum [Colored) 599 

85. Extreme Deformity of Skeleton due to Rickets 606 

86. Calvarium of a case of Ostitis Deformans [Colored) 614 

87. Arthritis Deformans, with Eburnation of Bone due to absorption of 

cartilage [Colored) 621 

88. Ankylosis of the Hip-joint [Colored) 626 

89. Cell-inclusions in Cancer of the Breast [Colored) 642 

90. Cell-nests in Cancer of the Lip [Colored) 649 

91. Tubular Epithelioma, from a case of Rodent Ulcer {Colored) ... 651 

92. Noli-me-Tangere [Colored) 654 

93. Medullary Carcinoma of the Breast 664 

94. Scirrhous Cancer of Breast {Colored) 665 

95. Brawny Infiltration of Breast in Cancer [Colored) 667 

96. (Edema of Arm in late stages of Cancer of Breast {Colored) . . . . 668 

97. Cancer of the Uterus 674 

98. Cancer of the Rectum 691 

99. Cancer of the Rectum, showing cylinder-cells 691 



14 LIST OF ILLUSTRATIONS. 

FIG. PAGE 

ioo. Alveolar Sarcoma 705 

101. Spindle-cell Sarcoma 706 

102. Giant-cell Sarcoma {Colored) 706 

103. Periosteal Sarcoma : amputation at the hip-joint {Colored) .... 714 

104. Retroperitoneal Lymphosarcoma, showing cells and stroma ... 731 

105. Lymphosarcoma {Colored) 7^2 

106. Fibro-adenoma of Breast (Colored) 739 

107. Diffuse Hypertrophy of the Breast {Colored) 741 

108. Adenoma of Thyroid Gland ( Colored ) 744 

109. Cystic Goitre {Colored) 744 

no. Accessory Thyroid Gland at the Base of the Tongue 745 

in. Section of Accessory Thyroid Tumor 745 

112. Thyreoglossal Tract 746 

113. Dermoid Cyst of Ovary {Colored) 750 

114. Fibroma (Colored) 754 

115. True Keloid {Colored) 756 

116. Naso-pharyngeal Fibroma {Colored) 757 

117. Myxoma {Colored) 759 

118. Lipoma of Thigh {Colored) 761 

119. Diffuse Lipoma of the Neck and Abdomen (Colored ) 762 

120. Enchondroma of the Tibia {Colored) 766 

121. Hyaline Enchondroma {Colored) 766 

122. Enchondroma of the Thumb (Colored) . . 767 

123. Mixed Cartilaginous Tumor of the Parotid Gland (Colored) . . . 767 

124. Hyaline Enchondroma of the Scapula ( Colored ) 768 

125. Ivory Exostosis of the Orbit {Colored) ...... 769 

126. Osteoma of the Lower Jaw ( Colored ) 770 

127. Neuroma from an Amputation-stump {Colored) 77^ 

128. Myoma of the Uterus {Colored) 774 

129. Angioma of the Lip and the Neck {Colored) 778 

130. Cavernous Angioma {Colored) 779 

131. Angioma of the Scalp (Colored) 780 

132. Lymphangioma (Colored) 782 

133. Fracture of the Neck of the Femur (skiagraph) 797 

134. Dislocated Patella (skiagraph) 798 

135. Renal Calculus (skiagraph) 799 

PAGE 

Plate I. Shaft of Femur, showing the results of osteomyelitis . . 209 

Plate II. Healing by first intention of an abdominal wound .... 223 

Plate III. Diabetic Gangrene 264 

Plate IV. Gangrene of Leg, following ligature of femoral artery . . . 265 



SURGICAL 



Pathology and Therapeutics. 



Surgical Pathology and Therapeutics. 



I. BACTERIOLOGY. 

If one were to search literature for the earliest accounts of the 
germ-theory of disease, it might be necessary to consult the oldest 
writings of which we have any knowledge, for even among the 
ancients there were those who thought that disease was due to the 
invasion of the system by minute organisms. But it remained for 
Leeuwenhoek, in 1675, actually to demonstrate with his rude micro- 
scope the presence of infusoria in the saliva. The theory of a con- 
tagiitm vivum was taken up from time to time after that date, and 
Robert Boyle, a prominent writer of the same century, maintained 
that he who obtained a proper comprehension of fermentation 
would be able to interpret satisfactorily the various phenomena of 
disease, particularly of fevers. Spallanzani, in the eighteenth 
century, and after him Gay-Lussac, in 1810, experimented with 
fermentation. Cagniard-Latour and Schwann, in 1837, recognized 
that alcoholic fermentation was due to the presence of a living 
organism, the yeast plant ; but this view was opposed with all the 
weight which the authority of Liebig could bring to bear upon it, 
who believed that fermentation was of a purely chemical origin. 

In 1840, Dr. Farr applied the term "zymotic" (Cuficoatz, a fer- 
ment) to certain diseases supposed to be due to a fermentative pro- 
cess. Ten years later Davaine demonstrated the bacillus anthracis 
in the bodies of animals which had died of splenic fever. It was 
at that time thought, however, that disease might arise de novo, 
and that, although organisms might be present, it was possible that 
they might have been formed by "spontaneous generation." It 
was not, however, until Pasteur, in 1858, unveiled the mysteries 
of fermentation, and later disproved the theory of spontaneous 
generation, that the relation of micro-organisms to disease began 
to be understood. Pasteur's law of fermentation has been likened 
in its importance to Newton's law of gravitation. It is undoubt- 



1 8 SURGICAL PATHOLOGY AND THERAPEUTICS. 

edly to him that credit should be given for furnishing the first 
reliable data from which the modern science of bacteriology has 
been evolved. Davaine, stimulated by Pasteur's researches, re- 
newed his studies of the bacillus of anthrax, and fully identified 
the organism as the cause of the disease. This bacillus may there- 
fore be placed, chronologically, at the head of the list of patho- 
genic bacteria. 

Pasteur showed also that putrescence is a form of fermentation 
due to the presence of micro-organisms, and he demonstrated that 
the changes taking place in the secretions of a wound were of a 
similar character. It was at about this time (1865) that Lister began 
to appreciate the bearing of this scientific work upon surgery, and 
commenced his studies upon the antiseptic treatment of wounds. 
This gave a powerful impetus to the study of the relation of micro- 
organisms to disease. No great advances were made at first, and 
much of the work done by Pasteur and his pupils at that period in 
the study of the diseases of man suffered for the want of suitable 
methods of investigation. Bacteria were cultivated almost exclu- 
sively in liquids, the bouillon of Pasteur. The cut surface of 
potatoes was found to give an idea of the coarse appearance of the 
growths, which the bouillon failed to show. When, finally, solid 
media were substituted as soil for the growths of the organisms — 
an improvement for which we are indebted to Koch, the great 
German observer — the separation of bacteria, and consequently 
their identification, for the first time became possible. 

Bacteria belong to the lowest order of the vegetable kingdom, 
and, with a few apparent exceptions, they may be said to form one 
group of the fungi, the schizomycetes or fission-fungi, in distinction 
from saccharomycetes or yeast-fungi, which produce alcoholic fer- 
mentation, and the mucorini or mould-fungi. The fungi are chiefly 
distinguished by the absence of chlorophyll, and therefore by their 
lack of power to assimilate inorganic substances, being thus depend- 
ent for their food upon living or upon dead organic matter ob- 
tained from other plants or from animals. Bacteria derive their 
name from fiaxrrjpiov, a rod, which many of them resemble in 
shape. 

The developed organisjn is in form a cell with a membrane and 
contents, but no nucleus. The contents consist of a more or less 
homogeneous protoplasm. This protoplasm possesses, in common 
with the nuclei of the cells of the tissues of the body, the property 
of being strongly stained by the aniline dyes. It is surrounded by 
a delicate membrane, which, according to Thoinot, appears like a 



BACTERIOLOGY. 19 

condensation of the peripheral layers of the protoplasm, from 
which it is with difficulty separated. According to De Bary, this 
membrane is a condensation of the innermost and most compact 
layers of a gelatinous envelope, and consists of a substance closely 
allied to cellulose. When stained with aniline dyes the difference 
between protoplasm and envelope is not visible, but by special 
methods of treatment the contents may shrink, and the envelope 
then becomes more apparent; or, when treated with water, the 
outer lavers swell up and their gelatinous nature becomes evident. 
The cells thus appear to be enclosed in a capsule. During the 
process of division this material holds the organisms together, and 
forms at times a zooglcea, or glue-like mass, in which they are im- 
bedded. It is this material which may give the cultures their form 
and consistency when growing on solid or in fluid media. In 
water it collects at times in large masses after the enclosed bacteria 
have attained their growth and have died, and becomes an efficient 
aid in the sand filtration of water-supplies. Many of the bacterial 
growths are in the presence of oxygen highly colored, being red, 
yellow, green, or blue. According to some this coloring matter is 
in the protoplasm, but according to others it lies outside the cells, 
as in the case of the bacillus prodigiosus, a beautiful red growth, 
where the pigment is in granules which have been exuded. 

A considerable number of the bacteria possess no movement 
whatever. Among these are the entire family of micrococci and 
some bacilli, as the anthrax and tubercle bacilli. The great major- 
ity of bacteria are, however, according to the conditions under, 
which they live, able to change from the motile state to the non- 
motile, or vice versa. When examined in fluid they may be seen 
moving about in serpentine-like curves, or they may have a sort of 
oscillating movement around a central axis. These movements of 
the bacilli are supposed by some to be effected by cilia projecting 
from different portions of their bodies, but these prolongations have 
been shown to be continuous, not with the protoplasm, but with the 
cell-membrane, and therefore, according to some authorities, are 
not organs of locomotion. Moreover, many bacilli which have 
active movements are found to possess no cilia whatever, being 
propelled by the vibratory movements of the flexible cells. The 
oscillations of the micrococci, so familiar to all observers, are not 
true movements of the cells, but are due to molecular agitation, 
the so-called u Browmian movement." 

The principal forms of bacteria are the small globular forms, or 
micrococci (x6xxo~ } a berry), the bacilli or staff-shaped bacteria, 



20 SURGICAL PATHOLOGY AND THERAPEUTICS. 

and the spirilla or spiral forms. The shape of the micrococci — or 
u cocci," as they are often called — is usually round, although some 
have a more or less oval contour. There are certain prefixes to the 
noun coccus that indicate the different groupings which this variety 
of bacteria take in their growth. Thus if the cocci tend to form in 
pairs, or two cocci are seen still connected together, they are termed 
1 ' diplococci ; ' ' those arranged in single rows of ' ' chains ' ' are called 
' ' streptococci ; ' ' and those grouped together in grape-like bunches 
are called ' ' staphylococci. ' ' ' The long, staff-shaped bacteria are 
known as "bacilli" {bacillus, a rod). When unusually long they 
have a slightly undulating shape, and are then known as ' ' lepto- 
thrix ' ' (leptothrix buccalis). Under the head of ' ' spirilla ' ' are in- 
cluded those bacteria which take the form of an arc of a circle or of 
a spiral. The " comma bacilli " of cholera are included in this cat- 
egory. There are in bacteriological nomenclature a great variety of 
terms which are hardly worth studying, as some of them have been 
discarded altogether, and about others little will be heard in labora- 
tory-work. The two principal forms seen in the different varieties 
of surgical bacteria are the micrococci and the bacilli. 

Nageli attached little importance to form : he believed that 
bacteria might not only change their shape from time to time, but 
in the course of years and under varying conditions also change in 
their pathogenic qualities. The same species, he believed, might 
at one time be concerned in the different forms of fermentation, at 
another in the decomposition of albuminous substances, or in typhus, 
cholera, or intermittent fever. The present opinion is that bacteria 
are divided into a limited number of varieties according to their 
action and form, but these varieties are never changed into other 
forms. The possibility of such a change from a harmless variety 
to a most malignant type, as Buchner supposed in the case of the 
hay and anthrax bacilli, is now understood to have been due to 
impurities of culture. Slight changes in form and appearance 
may be brought about by methods of preparation, staining, or cul- 
ture. The organism may vary also in appearance with age and 
activity, but there is nevertheless a form which it always preserves 
as the type of its normal development. 

Bacteria multiply either by division of the cells into two equal 
halves — that is, by "fission" — or by spore-formation. When a 
coccus divides, it becomes elongated or oval in shape, the middle 
portion becomes slightly contracted, and a delicate line appears 
between the two portions thus indicated. This line of division 
subsequently swells, and develops into a new membrane for each 



BACTERIOLOGY. 21 

of the daughter-cells thus formed. If the mother-cell is origin- 
ally separated from other cells, this division forms the so-called 
"diplococcus." If, on the contrary, a number of cocci are attached 
to one another and remain so during division in a linear direction, 
we have the "streptococcus" formation. If the fission takes place 
in two directions perpendicular to one another, we have as a result 
an arraneement of the cells such as is seen in the micrococcus 
tetragenus. If, however, segmentation takes place in different 
directions in the different cells, then we obtain the grouping of 
cells characteristic of the "staphylococcus." Each form of micro- 
coccus develops according to one of these methods alone, and never 
varies in its mode of growth. The bacilli elongate slowly before 
fission, but the division of this form is not so easily recognized as 
that of the cocci. 

A number of bacilli and a few spirilla, after going through dif- 
ferent stages of development, ultimately undergo sporulation before 
the cell is finally destroyed. When sporulation takes place, the 
protoplasm seems to shrink together at certain points into denser 
masses, that may grow in a few hours to an oval, a round, or even 
a staff-like, structure, which refracts the light more strongly than 
the surrounding protoplasm. The spore thus formed possesses an 
extremely dense enveloping membrane, which, like the covering 
of vegetable seed, protects it from external influences until it can 
find conditions favorable for future growth. The cell is some- 
what distended by the spore, which may occur either in the middle 
or at the pole. While the spore is growing the protoplasm disap- 
pears, and a clear, refractive material takes its place. When it has 
reached its full development, the cell-membrane undergoes a gelat- 
inous softening, the cell breaks up, and the spore becomes free. 
There is usually only one spore to each cell ; as to. the nature of its 
contents nothing is really known. The vitality of the spore is 
shown by the fact that it will resist a temperature more than double 
that which suffices to destroy the bacillus. When, however, the 
spore begins to develop into a bacillus, it loses its tough envelope, 
elongates, and assumes the appearance of the mother-cell from 
which it escapes. At this period it is much more easily destroyed 
even than the bacillus, which when full grown has of course a 
much stronger membrane than the newly-formed organism. The 
conditions most favorable to spore-formation are those under which 
the nutriment for the bacilli has been exhausted and they are about 
to die. The cells may then leave behind them the seed for a future 
growth. 



22 SURGICAL PATHOLOGY AND THERAPEUTICS. 

Bacteria, like all vegetable cells which do not contain chlo- 
rophyll, being unable to obtain for themselves sustenance from 
inorganic materials in the air or in the soil, grow only where 
organic material is present for their nourishment. They are to be 
found where organized life exists, except in the interior of the 
healthy organs of the body — in the air, in soil, in water, in cloth- 
ing, on the surface of our bodies, and in the intestinal canal. They 
grow best in alkaline or neutral media, and multiply, under favor- 
able conditions, with the most astounding rapidity : according to 
Cohn, a bacterium divides into two in the space of an hour, then 
into four at the end of a second hour, and into eight at the end of 
three hours. In twenty-four hours the number will amount to 
more than 16,500,000. "At the end of two days this bacterium 
will have multiplied to the incredible number of 281,500,000,000. 
.... The bacteria issuing from a single germ would fill the ocean 
in five days." Fortunately, the special conditions under which they 
can grow do not permit of any such rapid development. It is chiefly 
in dead organic substances that they find this favorable soil. It is 
now well understood that the process of decomposition is not only 
accompanied by them, but that through them alone it is also begun 
and carried on. To quote Cohn again : "Without the activity of 
bacteria all created things would retain their form and structure 
after death as well as the Egyptian mummies, or the wrecks sunk 
in the Dismal Swamp, or the bodies of the mammoth and rhino- 
ceros frozen for untold thousands of years in Siberian ice with 
uninjured hair and hide." 

Those bacteria which are concerned in the decomposition of 
dead substances of organic origin are called "saprophytic" or 
"saprogenic" (from oo~ip6z, putrid). A small number, however, 
grow in the living bodies of higher organisms. These develop at 
the expense of the tissues, and are, therefore, genuine parasitic 
organisms, whence they derive their name. Inasmuch as their 
presence in the body causes a morbid condition, they are generally 
called "pathogenic bacteria." Most of the parasitic organisms 
are, however, capable of growing in decomposing matter, and 
therefore may be saprophytic. 

In general it may be said that bacteria develop best at temper- 
atures varying from 30 to 40 C. There is little growth below 
20 C. or above 40 C. The saphrophytic forms prefer a tempera- 
ture of about 24 C. ; the pathogenic organisms grow best at or 
near the temperature of the body. 

In studying the fermentations Pasteur discovered that certain 



BA CTERIOL OGY. 23 

organisms could live without oxygen, and these he called anaerobic, 
while others were able to multiply only in the presence of air. The 
latter he called aerobic. 

The greater portion of the bacteria are aerobic, a slight dimi- 
nution in the amount of oxygen being sufficient to prevent their 
development. Others, however, can grow well in media rich in 
oxygen, but are able also to grow where there is no oxygen. The 
latter are sometimes called the ' l facultative-aerobic bacteria. ' ' Most 
of the pathogenic bacteria belong to this variety. The oxygen in 
the body, with the exception of the lungs, is not present in large 
quantities, and what little is found there is soon consumed. As illus- 
trating the action of the two kinds of bacteria, it may be well to 
give the following summary of Pasteur's theory of fermentation 
in decomposition: 

The process begins some twenty-four hours before outward manifestations 
are perceptible. During this time the bacteria (or the microbes, as Pasteur 
prefers to call them) fall upon the fluid, and the aerobic forms multiply with 
great rapidit}-, absorbing all the oxygen in the fluid. Owing to their great 
numbers, the fluid becomes cloudy. If the fluid is so shut off that oxygen 
cannot get at it, the aerobic forms die and are deposited at the bottom of the 
vessel. When all the oxygen is used up, the anaerobic begin to develop, and 
the process of decomposition advances in a corresponding ratio. If air is 
admitted, the aerobic organisms form a scum (mycoderma) on the surface, 
and gradually shut off all access of oxygen, so that the other variety may be 
able to develop. Mould-fungi may be found in this layer. Two chemical 
processes are going on in the mean time, owing to the action of the two 
varieties. The anaerobic cause a fermentation in the deeper parts by chang- 
ing the nitrogenous compounds into simpler but still complex combinations, 
while the aerobic, living at the expense of free oxygen, decompose these 
combinations still further until they are reduced to the simplest binary com- 
binations, water, carbonic acid, and ammonia. Although true fermentation 
is due to an organism that does not feed on oxygen, yet the process will go 
on better when free access of air is given, as this provides for the aerobic 
form, which is essential for the beginning and end of the process. If the 
decomposition is fully completed, the organisms die, and their remains will 
be destroyed by other bacteria; and this process will go on until the organic 
material is completely separated into the constituents of the atmospheric 
and mineral kingdoms. 

Light has also an influence upon the growth of bacteria; that is, 
the presence of sunlight is distinctly unfavorable to their develop- 
ment. 

Very important factors in the etiology of surgical diseases are 
the chemical products of the micro-organism, whether developed 
inside or outside the body. The saprophytic bacteria, although 
they are non-pathogenic, may produce powerful poisons by setting 



24 SURGICAL PATHOLOGY AND THERAPEUTICS. 

up decomposition in necrosed fragments of tissue. As decompo- 
sition is not a specific process, but a general expression for a 
multitude of different chemical combinations, it is not surprising 
that there should be formed a large number of chemical sub- 
stances the nature of which is still quite imperfectly understood. 
Most prominent among those who have studied the substances are 
Selmi and Brieger, who have given the name ptomaines (nrwfia, a 
dead body) to substances developed during these processes. Ab- 
sorbed into the body, the ptomaines give rise to that class of infec- 
tion known as "putrid intoxication," or saprsemia. Among the 
ptomaines is the sulphate of sepsin, described by Bergmann. 
Selmi has described a series of alkaloids obtained from decompos- 
ing substances, which alkaloids resemble atropine, morphine, and 
curare in their physiological action; and Nencki has obtained a 
substance, the so-called u collidin," which produces a similar effect. 
Brieger has added to these substances cadaverin, putrescin, and 
several others. Some of Brieger' s ptomaines produced the most 
profound toxic disturbance, and others are more or less harmless. 
To the former class probably belong the "toxines." The term 
ptomaine, however, is now largely used to indicate all products of 
bacterial growth. Some of these substances have a deleterious in- 
fluence upon the micro-organisms themselves. During the process 
of certain fermentations acids are sometimes developed that check 
further bacterial growth, and the process of fermentation comes to 
a standstill. More will be said upon this subject, however, when 
studying the process of infection. Leucomaines are animal alkaloids 
which result from tissue-metabolism in the body independently of 
bacteria. Their role in pathology is not yet well denned. 

In addition to the chemical products of fermentation, putrefac- 
tion, and infection there may be pigment-formation. The organ- 
isms which produce these substances are known as u chromogenic 
bacteria," having been classified by themselves by some writers. 
They probably do not directly form this pigment, but a basic sub- 
stance, wmich subsequently, by contact with oxygen or chemical 
substances in the media in which the bacteria are growing, pro- 
duces the characteristic color. Other bacteria produce phosphores- 
cences, but with both of these varieties surgeons have little to do. 

The anaerobic bacteria have a decided tendency to produce 
gas-formation, the nature of which is not yet understood. The 
cholera bacteria when cultivated have a peculiar odor, and those 
of decomposition may be present even in pure cultures of many 
forms of bacteria. 



BACTERIOLOGY. 25 

We come now to the study of these organisms, but all that 
will be attempted here will be to give a general idea of the best 
methods now in use in bacteriological laboratories. For details 
of this part of the subject the reader is referred to the text-books of 
Frankel and Baumgarten in the German language, Cornil and Babes 
in the French language, and Sternberg's Manual of Bacteriology. 

Before the methods now in use were adopted it was extremely 
difficult to see the very minute organisms under the microscope. 
In the process of staining and preparing a thin section every- 
thing was done to bring out as clearly as possible the anatomical 
elements of the tissues. The magnifying power used was suf- 
ficiently high for examining cells and fibres; higher powers cut off 
the light and made the picture obscure. There was obtained by 
the methods then employed a good view of what is called the 
"structure picture;" that is, the anatomical structure of the spe- 
cimen was satisfactorily observed. Now, in order to see bacteria 
properly, the specimen must be so arranged as to see as little as 
possible of the structure picture. These details are seen because 
their refractory power is different from the fluid in which the sec- 
tion lies. If the refracting powers were the same, these objects 
would not be seen. The elimination of the structure picture is 
accomplished by the Abbe condenser, which is placed beneath the 
object and between it and the mirror. In this way many more rays 
are collected and focused on the object than those thrown by the 
mirror alone. The field of vision is flooded with light even when 
very high powers are used, and the structure picture now disap- 
pears. If at any time it is desired to make the tissues more apparent, 
all that is necessary to do is to cut off some of the rays with the 
diaphragm, and a return can then be made to the conditions which 
existed when no condenser was used. The bacteria must be colored 
very deeply or they will also be obscured. The staining fluids in use 
in 1870 were principally carmine and haematoxylin. These fluids 
stained nuclei well, but they also stained the other elements of the 
tissue, and had but little if any power to stain bacteria. When the 
aniline dyes were tried a few years later, it was found possible to 
color the nuclei of the cells and the bacteria with great perfection. 
The picture thus obtained is called the " color picture. " If now 
it is desired to obtain the color picture alone, the condenser must 
be used without any diaphragm, but if it is desired to examine the 
structure of an uncolored section, if the condenser is used there 
must be employed the narrowest diaphragm in order to bring out 
the details. 



26 SURGICAL PATHOLOGY AND THERAPEUTICS. 

But it is not always necessary to stain bacteria in order to see 
them, and they can be examined in liquids also. Supposing it is 
desired to examine a flask containing bouillon in which bacteria 
are growing. A platinum loop, previously passed through the 
flame of a Bunsen burner and allowed to cool, is dipped into the 
solution, and a minute drop is carried on its point to a carefully- 
cleaned cover-glass. The fluid must be spread out over the cover- 
glass so as to form a thin and even film. The glass is then turned 
over and laid upon the object-glass very carefully, so that no air- 
bubbles or dry places are allowed to remain. The thinnest possible 
capillary layer of fluid should lie between the two glasses. 

If the organisms to be examined are growing on a solid culture- 
soil, a drop of distilled water is first placed on a cover-glass, and 
a small fragment of the culture is removed on the point of the 
platinum needle and rubbed up in the water. The glasses are 
arranged as before : a high power and immersion must be used 
with a medium diaphragm. The bacteria will be seen moving 
about in the liquid. This method is used chiefly for the purpose 
of determining whether a specimen contains micro-organisms or 
not. The liquid cannot be preserved for any length of time, for 
it soon dries up. The "hanging-drop " method obviates this dif- 
ficulty. A drop of the fluid is obtained by a loop with due pre- 
cautions, and is placed upon the centre of the cover-glass. A little 
vaseline is painted around the outer border of the cover-glass, 
which is then turned over and placed upon a hollowed-out object- 
glass. The vaseline seals up the chamber thus formed. Dry cul- 
tures can be examined in this way as well as fluid cultures. The 
fewer organisms there are in the drop the better. The border of 
the drop is the best part to study, as many bacteria will become 
attached to the edge of the drop, and will not, therefore, be so 
active in their movements. The form and size of the bacterial 
cell can well be studied in this way, and the preparations can be 
preserved for some time, cultures being taken from them later. 
The principal object of this method is to study the motility of the 
bacteria. 

The commonest way of examining bacteria is by some one of 
the usual staining methods. It is well to remark here that most 
varieties of organisms have not any special staining reaction pecu- 
liar to themselves, but can be stained by the ordinary cover-glass 
and aniline-dye method. 

The aniline dyes are derived from coal-tar products. Those 
most frequently used are the basic dyes, such as geutian-violet r 



BACTERIOLOGY. 27 

methyl-violet, methyl-blue, fuchsin, and Bismarck-brown. The 
element in them that holds the coloring matter is of a basic cha- 
racter. The acid dyes, as eosin and acid fuchsin, are used to obtain 
a diffused contrast stain in the tissues. 

With the basic dyes an excellent i ' color picture can be obtained. ' ' 
The acid dyes bring out not only the nuclei of the cells of the tis- 
sues, but their protoplasm also, and therefore produce more of a 
4 'structure picture," while the bacteria are hardly stained at all. 
The dyes seem to color the bacteria by virtue of a chemical action. 
They are usually dissolved in concentrated alcohol by shaking up an 
excess of the powder in alcohol and allowing it to stand and settle, 
and the fluid is then filtered immediately before use. These solu- 
tions are kept on hand and are diluted for use. A flask should be 
filled two-thirds with distilled water, and the alcoholic solution is 
then added drop by drop, as long as the fluid in the flask remains 
transparent. 

Gentian-violet is a strong and very desirable coloring agent, but 
it can easily overstain. 

Methyl-violet is less powerful, but also less durable. 

Fuchsin is one of the finest coloring agents : it does not over- 
color and is very durable. 

Bismarck-brown, which colors slowly, is usually employed as a 
diffuse stain, and it would probably not be used at all except that 
it is very suitable for photography. 

Many of the dyes can be reinforced and finer details can be 
brought out when desired by the addition of mordant substances, 
such as alum and carbolic acid. Ziehl's solution, used for this 
purpose, consists of the following ingredients : 

Fuchsin, 
Alcohol, 
Carbolic acid, 5 per cent, solution, 

Heating the solution during the staining process also makes the 
coloring more intense and durable. A high degree of heat is, how- 
ever, not suitable for sections, but rather for dried specimens on 
the cover-glass, as will presently be seen. 

If the preparation has been too deeply or generally stained, the 
excess can be removed by washing out in water or in alcohol. A 
weak solution of acetic acid may be employed for this purpose. 

One of the best ways of demonstrating the presence of bacteria 
in tissues is that known as "Gram's method." The preparation 



gl 


n. 


1. 


c 


c. 


10. 


c. 


c. 


90. 



28 SURGICAL PATHOLOGY AND THERAPEUTICS. 

is first placed for one or two minutes in a solution of gentian- or 
methyl-violet in aniline-water. It is then placed for one minute 
in the following solution : iodine, i part ; iodide of potash, 2 parts ; 
distilled water, 300 parts. This solution forms with the dye a 
deposit confined entirely to the bacteria. The preparation is now 
placed in absolute alcohol until it appears colorless to the naked 
eye. The alcohol is removed with blotting-paper, and the speci- 
men is finally mounted in Canada balsam. This is considered one 
of the best methods of staining for those bacteria which it does not 
decolorize. If desirable there can now be obtained a staining of 
the tissues with carmine or eosine, and thus "a double staining" 
be accomplished, the bacteria being of a deep-blue color, while 
the tissues have the contrasts which the different shades of red 
afford. This method, though difficult in execution and inapplica- 
ble to many forms of bacteria, gives excellent results in those cases 
to which it is adapted, and the inability of a bacterium to take this 
stain is often of diagnostic value. 

Supposing, now, it is desired to examine the blood, or the juices 
of internal organs, or sputa for bacteria, or a culture, and to 
employ the staining process — for uncolored preparations are of 
little or no use to the bacteriologist — the first step is to spread out 
a minute portion of the substance, as has already been shown, 
upon the cover-glass with a sterilized platinum needle. To make 
the layer as thin and even as possible a second cover-glass is placed 
over the first and the two glasses rubbed gently together. When 
separated by carefully sliding apart the glasses afford two prepara- 
tions. They must now be laid down with the specimen uppermost, 
and be protected by a bell-glass while drying. One of the great 
difficulties in staining such a dried specimen is that, as soon as the 
dye is allowed to come in contact with it, the albuminous portions, 
if such are present, swell up and become fluid again, and precipi- 
tate particles of colored matter which ruin the preparation. This 
is overcome, however, by heating the cover-glass by passing it 
through a flame of a Bunsen burner three times quickly, the prep- 
aration being uppermost. This heating does not seem to interfere 
at all with the form or with the staining power of the bacteria, 
and it fixes the specimen upon the cover-glass. The coloring fluid 
selected is next dropped upon the specimen, which is afterward 
washed in distilled water, and the specimen is now ready for 
mounting. The preparation may be made upon the slide instead 
of upon the cover-glass, and be examined without the intervention 
of any cover-glass. This gives greater facility of manipulation, 



BACTERIOLOGY. 29 

and the slide can readily be cleansed if a permanent specimen is 
not desired, but, if this be done, great care must be taken of the 
lens. 

There are one or two modifications worth mentioning. If it is 
desired to remove any haemoglobin present, the glass should, after 
drying, be placed for a few seconds in a 1 to 5 per cent, solution of 
acetic acid, and, after washing in distilled water, be dried again 
before staining. If it is desired to clear up the specimen so that the 
cells shall not be visible under the microscope, there can also be used 
the acid, or, better still, two or three drops of a 33 per cent, solu- 
tion of potash or soda in a watch-glass of distilled water. This 
leaves the contours of the nuclei still faintly visible. Masses of 
fat are undesirable in such specimens for they confuse the picture 
and are likely to give deceptive imitations of bacteria, owing to 
the crystals which form. This material is disposed of by heating 
the cover-glass after allowing a drop of the dilute potash to fall 
upon the specimen. The fat is then dissolved and becomes invis- 
ible. The same purpose can be effected by dipping the specimen 
in chloroform and afterward in alcohol. The specimen, when satis- 
factorily prepared, may be mounted in water, and Frankel strongly 
recommends this to be done, as the shape of the bacteria is thus pre- 
served and their membranes are better shown. If it is necessary 
to mount them in a permanent shape, the specimens can be placed 
in Canada balsam, dissolved in xylol rather than in chloroform, 
as the latter robs the bacteria of the coloring matter and the speci- 
men quickly fades. 

It is exceedingly difficult to stain spores. By the ordinary 
methods of staining spores remain uncolored and appear as highly- 
refractive bodies, which are better seen in recent cultures, owing 
to the contrast with the highly-colored protoplasm of the young 
bacilli. Spores may, however, be stained if they are exposed for 
some time to heat. The cover-glass containing the specimen to be 
stained may be placed in a hot-air oven at a temperature of 120 C 
for an hour, or at a higher temperature for a shorter time, or it 
may be passed eight or ten times through the flame of a Bunsen 
burner. The spores may then be stained with an aqueous solution 
of fuchsin or methyl-violet. This method so injures the bacilli 
that they do not color as well as usual. If a double staining is 
desired, Holler's method may be used. 

According to Moller, the material is placed on a cover-glass, and is allowed 
to dry ; it is then passed three times through a flame, or is left for two min- 
utes in absolute alcohol ; it is then placed in chloroform for two minutes and 



SO SURGICAL PATHOLOGY AND THERAPEUTICS. 

washed in water, and afterward from half a minute to two minutes in a 5 per 
cent, solution of chromic acid, and again washed in water ; a solution of car- 
bolic fuchsin l is now poured over the glass, which is heated in a flame until 
boiling occurs for sixty seconds, when the solution is poured off and the 
preparation is decolorized in a 5 per cent, solution of sulphuric acid and 
washed in water. It is next placed in an aqueous solution of methylene-blue 
or of malachite-green, and again washed in water. The preparation is now 
dried and mounted in balsam. The spores are stained dark red, and the 
protoplasm of the bacilli is blue or green. 

To prepare pathological specimens for bacteriological study the 
portions to be examined should be cut into pieces about half an 
inch square and placed in absolute alcohol. The alcohol must be 
changed once or twice, and at the end of a few days the specimens 
are ready for the section cutter. 2 The sections can be taken out of 
water or alcohol and placed in a dilute coloring fluid for from five 
minutes to an hour or more. They are then placed in acidulated 
water or in 60 per cent, alcohol to remove the excess of coloring 
matter; they are washed afterward in water, which must be re- 
moved by alcohol before placing the sections in oil of cloves, or, 
better, in oil of cedar, whence they are taken and permanently 
mounted in Canada balsam. If a section is overstained, washing 
in alcohol will remove the superfluous color better than water. 
Alcohol is sometimes too powerful in its bleaching effects, and it 
is therefore desirable to remove the water by evaporation before 
placing the section in oil. If it is desired to make a double stain- 
ing, Bismarck-brown in weak solutions or picrocarmine may be 
used. Frankel thinks it is better to reverse the process; that is, 
to stain the nuclei first and the bacteria afterward. It requires 
considerable experience to distinguish readily all objects which are 
of non-bacterial origin, but closely resembling micro-organisms. 

Examination with the microscope alone would not have accom- 
plished a great deal in the science of bacteriology. It was neces- 
sary at first, in order to preserve live bacteria for study, that a 
medium should be provided in which they could grow. Although 
Pasteur accomplished a great deal with his bouillon culture-fluids, 
it was found that there were certain disadvantages inherent in this 
method of investigation that offered obstacles to further progress. 
The facility which a fluid offers for indefinite growth in every 
direction makes it exceedingly difficult to separate the different 
varieties of bacteria from one another. This differentiation was 
attempted by taking an exceedingly small quantity from one flask 
and placing it in a fresh flask, and later repeating the same opera- 

1 See page 57, Surgical Bacteria. 2 See Appendix. 



BACTERIOLOGY 31 

tion, until finally the dilution was so great that but one organism 
was found in each drop, and the special form was thus obtained. 
The slightest error in the process, however, speedily reproduced 
an impure culture. It was Koch's great merit to have systematized 
the first rude attempts to grow bacteria on solid culture-media and 
to bring the art of culture to its present state of excellence, though 
undoubtedly we are as yet but upon the threshold of this new field 
of science. 

The great advantage of the solid-culture method lies in the 
opportunity which it gives to isolate the different varieties of bac- 
teria from one another. Having accomplished this, bacteria can 
now be planted rapidly from fresh growths until the organism has 
passed through several generations, with the certainty that there 
will result a growth which is not only a particular kind of bacteria, 
but one that has now become entirely disassociated from the orig- 
nal source from which it was taken. To provide a suitable soil the 
soil must not only contain those ingredients which bacteria need 
for their growth, but it must also resemble, as nearly as it can be 
made, the chemical constitution of those tissues which the organ- 
ism attacks. It is also absolutely necessary that the material used 
must entirely be free from organisms of any kind, and that it 
must be sterilized thoroughly. For fluid culture-media a watery 
extract of meat or a bouillon is used ; for the solid culture-media 
an admixture of gelatin, or a Japanese substance known as "agar- 
agar," or coagulated blood-serum, potato, or egg-albumin, etc., is 
employed. 

Sterilization of culture-media is a most important feature of 
bacteriological technique. It may be effected by heat or by filtra- 
tion. The former method is the one chiefly employed. 

Bacteria which do not form spores are killed at a comparatively 
low temperature. Sternberg found that the pyogenic cocci required 
the highest temperatures, and that they were killed by an exposure 
for ten minutes to a temperature of 62 C. All bacteria are de- 
stroyed in one or two minutes, in the absence of spores, by exposure 
to the action of boiling water or of steam. A very much higher 
temperature is required for the destruction of micro-organisms 
when dry heat is used. The spores of bacilli have a much greater 
resisting power, and in some cases are not destroyed by a boiling 
temperature maintained for several hours ; but the majority are 
killed by being subjected to the boiling temperature of water for a 
few minutes. Fractional sterilization is employed for certain nutri- 
ent media, for the reason that prolonged boiling may injure them. 



32 



SURGICAL PATHOLOGY AND THERAPEUTICS. 



This method is based upon the supposition that some of the more 
resistant spores may be present in the culture-material, and that 
bacteria may be developed from them after sterilization by the 
ordinary method. A repetition of the process will therefore destroy 
the growing bacteria which are developed from such spores. The 
culture-material is subjected for a short time to the temperature of 
boiling water ; after an interval of twenty-four hours the operation 
is repeated for the purpose of destroying those bacteria which may 
have developed in the mean time from spores. This is repeated at 
corresponding intervals from three to five times. 

Test-tubes and all glass and metal objects which it is intended 
to use in the laboratory are sterilized by dry heat. A hot-air oven 
made of sheet iron with double walls and shelves is used for this 
purpose. A much higher temperature is needed under these con- 
ditions than when moist heat is used. Micrococci and bacilli are 
not destroyed below a temperature of 120 C. It is necessary to 
raise the temperature to 140 C. to destroy spores, and the degree 
of heat should be maintained for an hour or more. When, there- 
fore, apparatus is sterilized, a tem- 
perature of about 150 C. should 
be maintained for this length of 
time. 

As moist heat acts more rapidly 
upon bacteria, the sterilization by 
steam is extensively used. Koch's 
apparatus consists of a copper or a 
zinc cylinder which is covered with 
a jacket of felt. There is an open- 
ing at the top for the escape of 
steam, and another through which 
a thermometer may be inserted. 
The water in the cylinder is heated 
by a Bunsen burner, and the steam 
is maintained at a temperature of 
ioo° C. Near the lower third of 
Fig. i.— Arnold Sterilizer. the vessel is a perforated shelf 

which is placed sufficiently high 
so as not to come in contact with the water. The Lautenschlager 
sterilizer is so arranged that a current of steam descends from above 
upon the objects to be sterilized and passes out through the bottom 
of the vessel. The Arnold sterilizer (Fig. 1), which is largely used 
in the United States, is convenient, as it is so arranged that steam 




BACTERIOLOGY. 



33 




can be obtained rapidly with a small quantity of water. It has the 
advantage also of great simplicity. The autoclave is a form of 
sterilizer by means of which steam can be obtained under pressure. 
Under these conditions a single sterilization at a temperature of 
115 C. for half an hour suffices. This apparatus is, however, 
expensive. 

Test-tubes which are to contain the nutrient media are plugged 
with cotton, which acts as a filter, allowing the access of air, but 
preventing the entrance of bacteria. After sterilization in the 
hot-air oven the tubes are ready to be charged with the nutrient 
media. The bouillon peptone-gelatin is subjected to a temperature 
of ioo° C. for ten minutes at intervals of twenty-four hours, four 
days in succession. Bouillon and agar-agar jelly may be prepared 
in the same way or be steamed once for an hour. The sterilization 
of culture-material should be tested by placing it for a 
few days in an incubating oven at 30 to 35 ° C. 

The culture-media should be slightly alkaline, and 
should resemble as closely as possible the fluids of the 
body. 

To make a suitable bouillon, cut up 500 grammes of lean 
meat, place it in a pint of water, and let stand for twelve hours 
in a cool place. Now squeeze through a loose cloth, a little 
peptone being then added to take the place of albuminous 
substances precipitated on heating. Boil in a water-bath or 
in steam three-quarters of an hour, and neutralize with a satu- 
rated solution of the carbonate of soda. Boil again one hour, 
and the coagulable albuminoids will be precipitated or will 
float upon the surface. Filter through paper wet with distilled 
water. The bouillon must still be kept alkaline, or at least 
neutral, and should not, after repeated boiling, become in the 
least cloudy. The white of an egg, added before boiling, helps 
to clear up the fluid. The fluid thus prepared should be placed 
in sterilized test-tubes, and the tubes thus charged must finally 
be sterilized by the fractional process. 

Bouillon is a good material to use if it is desired to 
measure a given number of bacteria, as each drop will 
always have about the same number, or if it is desired 
to watch their development in the hanging drop or to 
obtain large numbers of bacteria. One of the first 
forms of solid media used was the cut surface of FlG< 2 
cooked potatoes. 





Potato- 
culture. 



A practical method for preparing potatoes for planting bacteria is as 
follows : Good-sized potatoes should be selected, and the ends sliced off. 
They are then punched with an apple-corer. Cylinders about two inches in 
3 



34 SURGICAL PATHOLOGY AND THERAPEUTICS. 

length are thus obtained, which are split obliquely. These pieces are allowed 
to soak in cold water for two or three hours, and are then placed in sterilized 
test-tubes containing a fragment of glass to support the potatoes in such a 
way that they will not be immersed in the water of condensation. The tube 
thus charged is sterilized by the fractional method (Fig. 2). 

Gelatin possesses the much greater advantage of providing a 
solid material which is at the same time transparent. 

Nutrient gelatin should thus be prepared: 1000 parts bouillon, 10 parts 
peptone, 5 parts salt, too parts gelatin are the proportions of the ingredients. 
Shake and heat to melt the gelatin. Soda solution should be used for neu- 
tralizing. Boil the mixture half an hour to precipitate coagulable substances, 
and filter. The filter must be warm. The resultant fluid must be clear, and 
must remain so on boiling. In sterilizing it must not be subjected too long 
to heat, as heat injures the stiffening properties of the gelatin. Steaming 
fifteen minutes a day for three days is sufficient. 

The disadvantage of gelatin is its liability to become softened 
by heat, and it therefore cannot be used for making plates of those 
organisms requiring for their development a temperature of 30 C. 

Agar-agar is a substance resembling isinglass, prepared in the 
far East from a gelatinous form of algse. It is nearly soluble in 
hot water, forming a jelly which melts only at 90 C. and hardens 
again at 40 C. The preparation of agar is much harder than that 
of gelatin, on account of the greater difficulty of filtration. The 
addition of 6 to 7 per cent, of glycerin to the preparation makes it 
a suitable soil for the growth of tubercle bacilli. 

Agar-agar is thus prepared : To 100 parts bouillon, 10 parts peptone, and 5 
parts salt are added 1 to 2 parts agar-agar. This mixture must be boiled for 
two or three hours before filtering. 

Blood-serum may be employed for the growth of a great variety 
of bacteria, but more particularly for those organisms which do not 
develop readily on other media. The blood is received in sterilized 
cylinders, which remain on ice for two days to allow the coagula- 
tion to be completed. The serum is then removed with sterilized 
pipettes and placed in test-tubes. Human serum, ascitic, hydro- 
cele, and ovarian fluids have been used in the same way. 

The tubes thus charged are sterilized by the process of discon- 
tinuous heating. They are left in a hot-water bath of a tempera- 
ture of 6o° C. for about an hour daily for from five to seven days. 
Koch has devised an apparatus for this purpose. The tubes are 
left in an oblique position, so that a large surface may be exposed 
for culture purposes. After being sterilized the serum is solidified 
by a careful exposure to a temperature of about 68° C, which 
causes it to coagulate, forming a transparent jelly-like mass. 



BACTERIOLOGY 



35 



A great many forms of organisms will not grow upon any of 
these cnltnre-soils or on any that are now used. This can easily 
be demonstrated by trying to inoculate them with a drop of saliva 
which under the microscope can be seen to contain a great variety 




hi i|, 



Fig. 3. — Method of Filling Test-tubes with Nutrient Material. 1 



of organisms. The resulting culture will contain but compara- 
tively few of these forms. About 10 ccm. of the culture-media are 
placed in each test-tube. The gelatin is allowed to harden with 
the test-tubes in the vertical position, and is inoculated by thrust- 
ing the platinum needle, charged with the infected material, into 
the gelatin. This is the so-called "stab-culture" or "stick-cul- 
ture." The agar-agar and blood-serum are usually allowed to 
solidify while the test-tube is in an oblique position, thus giving as 
large a surface as possible for the bacterial growth. 

If, now, there is a great variety of bacteria growing in a speci- 

1 The funnel containing the material to be used is protected from the air by a plate of 
glass. A rubber tube connects the funnel with a pointed glass nozzle, and the flow of fluid is 
controlled by a Mohr check-cock. A plug of cotton is held between the fingers of the 
right hand, and the tube is held in the left hand. On the right are the empty sterilized tubes, 
and on the left are the baskets containing the tubes which have been filled. 



36 



SURGICAL PATHOLOGY AND THERAPEUTICS. 



men (as in faeces), they can be separated by plate-cultures. Three 
test-tubes containing the gelatin mixture are melted in a water- 
bath at a temperature of from 30 to 40 C. : a very minute frag- 
ment of the material to be examined is placed in one of the 
tubes, and is thoroughly mixed with the culture-fluid ; from this 
" original" tube, as it is called, three drops of the liquid are trans- 
ferred to the second tube, and from the second tube three drops are 
transferred to the third. The culture-fluids are thus progressively 
made more dilute. The fluid gelatin is poured into Petri dishes (Fig. 
4) or upon square glass plates, and is allowed to harden. The 

plates are then placed in 
a large double dish upon 
little trays, one above an- 
other. Wet filter- paper is 
placed in the bottom of 
the dish to keep the air 
moist. The bacteria in 
the fluid are thus more or 
less widely separated from 
one another, and the vari- 
ous colonies are given 
an opportunity to develop 
separately. There is thus 
an opportunity not only 
to determine the number of varieties, but also to contrast them 
with one another. Some liquefy the gelatin ; some are pigmented. 
If it is desired to examine a particular colony, the plate containing 
this growth may be placed under a microscope of low power, or, 
under favorable circumstances, a cover-glass may be placed upon 
the colony and the oil immersion may be used ; or the cover-glass 
with the adherent colony may, after removal, be dried and stained 
in the usual manner. Many bacteria that cannot be separated in 
any other way may be obtained by the plate method. 

The colonies it is desired to study must now be transferred to 
culture-tubes, where they are more protected from infection from 
outside sources and can more carefully be studied. A minute 
fragment is taken from one of the colonies while observing it 
through a lens of low power. The needle with the fragment thus 
obtained is thrust deeply into a gelatin culture-tube. As the cul- 
ture grows it is not difficult to determine whether it is pure or not. 
Another mode of transferring the culture from the plate is to draw 
the platinum needle over the surface of the agar-agar, which is 




Fig. 4. — Petri Dish with Colonies. 



BACTERIOLOGY. 37 

usually allowed to harden by placing the tube in an oblique posi- 
tion. This allows the culture to grow upon the surface and in the 
presence of oxygen. As a rule, the gelatin and agar cultures will 
live for three or four months ; it is better, however, to renew the 
cultures every six weeks. 

The anaerobic bacteria are much more difficult to cultivate. 
The culture-media must be treated with substances which rob them 
of their oxygen. The organisms must thoroughly be mixed with 
the gelatin. After spreading the fluid gelatin containing these 
organisms on plates, they are covered, before hardening, with thin 
leaves of mica to cut off the oxygen, and are sealed up by paraffin 
poured over the edges of the mica. Or the gelatin may be boiled 
in the test-tube before the bacteria are mixed with it, and then 
quickly hardened. The boiling process drives out the oxygen, and 
the deeper layers in the tube are protected from oxygen by the 
upper layers, and anaerobic bacteria can then be made to grow. 
This method, which has the advantage of supplying different 
amounts of oxygen, is available for those anaerobic forms that can 
grow where there is no oxygen, but prefer oxygen. They will be 
found in the upper layers of the tube. Those which can only grow 
where there is no oxygen will be found at the bottom of the tube. 

If the gelatin in a tube is punctured by a platinum needle 
armed with anaerobic bacteria, the deeper portions only of the 
puncture line will show signs of growth ; as the layers are reached 
where oxygen still exists, the growth will stop. Bggs may be 
used for the same purpose. A small puncture having been made 
and the organisms introduced, the hole is sealed up with collodion. 
The small amount of oxygen existing in the egg is soon replaced 
by sulphuretted hydrogen. A method of cultivating anaerobic 
bacteria in the presence of hydrogen gas will be described in con- 
nection with the tetanus bacillus. 

If it is necessary to keep the culture medium at a high temper- 
ature, an oven must be provided for the purpose. That now 
generally in use has a double wall which contains water heated 
by a gas-jet. The degree of heat is indicated by a thermometer 
and is regulated by some automatic arrangement. The escape of 
heat from the sides of the oven is prevented by a felt jacket. 

The action of the pathogenic bacteria in disease is not yet fully 
understood. One of the earliest theories assumed that the presence 
of bacteria in large numbers in the organs acted mechanically to 
impair their functions. This is probably true to a limited extent 
only. According to Frankel, their action is explained by the 



38 SURGICAL PATHOLOGY AND THERAPEUTICS. 

development of a specific, exceedingly poisonous substance having 
a very deleterious influence upon the organism. This poison, like 
that of the serpent, may spread itself all through the body, and, 
although small in quantity, may produce very marked effects. It 
probably varies greatly in amount in different cases. 

As to whether the poison is a product elaborated from the bac- 
terial cells as a specific excretion, or is the result of a tissue-meta- 
morphosis brought about by the organisms, which select from the 
tissues such substances as are most nutritious to them, is a point 
about which authorities differ. Opinions at the present time are 
pretty evenly divided upon this point. It can easily be understood 
that when one or two important elements are taken from the 
chemical composition of a cell or from the matrix in which it lies, 
an entirely new chemical compound may be the result. The 
chemical nature of the tissues in which the bacteria grow is there- 
fore an important element in determining the nature of the com- 
pound that will be formed. It is a well-known fact that the albu- 
minoids, for instance, are necessary for the development of most 
toxines. Poisonous substances may be developed in one case 
which in another fail to form, owing to the absence of some 
important basic substance. 

The result of such action of bacteria upon the cells of the body 
is to produce what is known as " irritation." If the action is suf- 
ficiently powerful, death of the cell will ensue, but if it be less 
powerful and continued for a certain length of time, the result 
will be a growth of new cells. This action is probably exerted 
through the endothelium of the capillaries, for we often see bac- 
teria enclosed within such cells. These cells exercise an important 
influence upon the nutrition of the organ, as they determine to a 
certain extent what chemical substance shall be allowed to pass 
through the vessel's walls for its nourishment. The result of such 
a disturbance of nutrition upon the organ will of course affect its 
functions, and this may go to the point of producing all trie 
phenomena of an inflammation. The production of a general con- 
stitutional disturbance will be found discussed at more length in 
another chapter. It may merely be said here that the most gene- 
rally received opinion is that substances are produced which have 
a ferment-like action and increase the tissue-metamorphosis greatly 
throughout the body. Baumgarten, however, believes that the 
growth of foreign organisms in the body is alone sufficient to 
account for all the phenomena of fever without assuming develop- 
ment of a particular virus. 



BACTERIOLOGY. 39 

It is a well-known fact that ptomaines can be separated from 
their bacteria, and, if introduced into the body, can produce local 
or general disease. That apparent suppuration can be produced 
experimentally in this way has finally, after much discussion, been 
determined in the affirmative. Introduced in large quantities, 
ptomaines may excite grave constitutional disturbance. These 
substances are not, however, multiplied and reproduced within the 
body ; they exert only a passive role. Such a condition is known 
as ''intoxication" or "toxic infection," as distinguished from the 
"septic infection" of bacteria. 

The question of immunity of the living body to the action of 
certain bacteria is one which has received a vast amount of atten- 
tion, and is still unsettled. Leading up to this question is that of 
the mitigation of the virulence of bacteria and the production of a 
vaccine, as first broached by Pasteur. This change in the activity 
of the organisms may be produced by allowing them to grow for 
an unusually long time in their culture-media. In this w T ay the 
power to develop in the living body seems gradually to be lost. 
This change in the bacteria shows itself in a more vigorous growth 
upon the soil than took place at first, when it was less accustomed 
to its situation. The organisms of chicken cholera and anthrax 
were first successfully cultivated so as to produce a "vaccine" for 
these diseases. 

Another way of weakening the action of the bacteria is to mix 
with the culture-media certain chemical substances which' are 
poisons to them, but not sufficient in amount to kill them. Roux 
weakened the anthrax bacillus in this manner by mixing bichromate 
of potash with the bouillon. This experiment suggests an expla- 
nation of the cause of the insusceptibility of certain animals to some 
forms of bacteria which are passed through them, owing to the pres- 
ence of peculiarly hostile chemical compounds in their blood. A 
weakening of their power is also brought about by exposure to 
atmospheric pressure, sunlight, and high temperatures. The cause 
of the weakening of virulence is supposed to lie in a degeneration 
of the bacterial cell-protoplasm, but there is no marked change 
visible to the eye. 

How far this process of protective inoculation can be carried 
in the control of disease is a very doubtful question, but the fact 
has been definitely established that under certain circumstances 
a mitigated virus can render the most virulent poison harm- 
less. Bitter has shown that the bacilli of the anthrax vaccine 
develop only in the immediate neighborhood of the point of infec- 



40 SURGICAL PATHOLOGY AND THERAPEUTICS. 

tion. Heuppe and Wood were able to produce the same immunity 
to anthrax by the injection of organisms, quite of a different nature, 




Fig. 5. — Bacteriological Syringe. On removal of the rubber bulb this instrument can be 
sterilized by dry heat. The almost capillary lumen permits great accuracy of dosage (H. C. 
Ernst's modification of the Koch syringe). 

and not even pathogenic, into animals which ordinarily were very 
susceptible to the disease ; and the same immunity has been pro- 
duced by the injection of peculiar forms of albumin in no way 
connected with bacterial growth. According to Frankel, the pro- 
tection afforded by vaccination is therefore the result of many 
substances which are chiefly of bacterial origin. According to 
Pasteur, immunity is acquired by the exhaustion of a chemical 
substance necessary for the growth of the micro-organisms. The 
" retention " hypothesis assumes that the products of tissue-meta- 
morphosis remain behind after the first invasion, and prevent a 
return of the same kind of organism. According to Frankel, this 
hypothesis has fewer objections than any other. It is known that 
in some forms of fermentation substances are developed which 
prevent the further growth of organisms, and may even prove 
poisonous to them. 

The phagocyte theory of Metschnikoff is still exciting great 
attention, and although it has already been referred to in another 
chapter, an allusion to it in this connection cannot be avoided. 

The first studies were inade upon the Daphniidae ( u water fleas"). 
The needle-shaped organisms which invaded the intestinal canal 
and the tissues of its body were surrounded by leucocytes and taken 
up into their protoplasm, and there were changes thus produced in 
them which suggested a sort of digestive process. Metschnikoff 
also placed fragments of liver taken from a rat, dead of anthrax, 
under the skin of a frog, and found them later infiltrated with 
leucocytes in whose protoplasm many of the bacilli were found. 
He found also that the bacilli, when artificially weakened and 
injected into warm-blooded animals, were quickly taken up by the 
leucocytes, but when injected with their full strength still pre- 
served, only a few were found in the spleen thus enclosed by 
leucocytes. He accordingly advanced the theory that the leuco- 



BACTERIOLOGY. 41 

cytes, like their ancestors, the amcebce, had a certain instinctive 
propensity, in search of material for their nourishment, to consume 
the invading organisms. Hence the term "phagocyte." The 
protective influence of vaccination was supposed by this observer 
to be due to the power which the consumption of weaker forms of 
bacteria gave to the leucocytes to devour the more virulent varie- 
ties. The opponents of the phagocytosis theory, who are numer- 
ous, claim that the phagocytes eat up the bacteria only when the 
latter have been killed by other influences. It should be men- 
tioned that the leucocytes are not permanent bodies, therefore a 
capacity on their part for transmitting this acquired power to their 
descendants must be assumed if this theory is adopted. 

Although the phagocyte theory seems to play a certain role in 
the problem of immunity, the general weight of opinion seems at 
present to be opposed to this very attractive theory in its entirety, 
and to lean to the view that predisposition to disease means a 
favorable culture-soil for the bacteria in question, and immunity 
from disease means a soil unfavorable to those organisms. The 
chemical constitution of the blood-serum is therefore probably a 
more important factor in resisting or in favoring the invasion and 
growth of bacteria than any peculiar powers possessed by the white 
blood-corpuscles. 

When it is realized how hard it is to cultivate certain forms of 
bacteria on artificial media, it does not seem surprising that the 
varying condition of the chemical constitution of the blood and 
tissues of different animals, or the changes occurring at different 
periods of life of the same individual, should produce soils at times 
unfavorable to the growth of pathogenic bacteria. 

Buchner thought that this destructive power of the blood-serum 
lay in the amount of salts it contained and the albuminates with 
which they are combined. If, for instance, a rat is treated with 
phosphate of lime, which causes a production of acid in the body, 
the high grade of alkalinity of the blood will disappear and the 
animal will become susceptible to the anthrax bacilli. If a large 
number of bacilli are injected into the same kind of animal, a 
similar result will follow, for, although many of the bacilli are 
killed by the unfavorable conditions they meet with in an insus- 
ceptible animal, the dying organisms liberate acids and pave the 
way for an invasion of the system by the survivors. It should not 
be forgotten that an antagonism exists between the healthy living 
tissues of the body and bacteria. If these organisms gain an 
entrance into the circulation, they usually disappear rapidly. It 



42 SURGICAL PATHOLOGY AND THERAPEUTICS. 

was at one time supposed that they were excreted with the bile or 
the urine, but this is now known not to be the case ; for it is 
established that an uninjured membrane will not allow the bacte- 
ria to pass through it, as a rule. Wyssokowitsch found that they 
were deposited chiefly in three organs, the liver, the spleen, and 
the bone-marrow. If, on the one hand, the organisms are non- 
pathogenic, they are destroyed in these organs ; on the other hand, 
if they are pathogenic, they have an opportunity to develop in those 
localities. There are three routes through which bacteria can 
obtain an entrance into the body : First, through the skin, generally 
through some wounded surface, although it has been shown by 
Garre that the apparently uninjured skin does not offer an insur- 
mountable barrier ; secondly, through the digestive canal ; and, 
thirdly, through the respiratory tract. 

The pathogenic bacteria may be defined as those which stand in 
a causal relation to certain well-marked morbid conditions, and 
they are regarded as the specific agents which produce the patho- 
logical symptoms. 

Koch lays down as a crucial test that certain conditions must be 
fulfilled before it can positively be asserted that a given organism is 
the specific cause of a disease. These are : it must be found in all 
cases of that disease ; it must be found in no other disease ; and 
it must appear in such quantity and be so distributed that all 
symptoms can be accounted for by its presence ; also, that the bac- 
teria must be capable of being isolated from the diseased tissues, 
and be grown upon some of the artificial culture-media, and when 
injected into an animal must be capable of reproducing the disease. 
Although all these conditions cannot be fulfilled, yet the constant 
presence of a single variety of bacteria in a given disease renders, 
it highly probable that it is the cause of the disease. 



II. SURGICAL BACTERIA. 



The number of bacterial forms found in, and fully identified 
with, surgical diseases is not large, yet it can safely be said, from 
the present standpoint of our knowledge, that the traumatic infec- 
tive diseases are all to be accounted 
for by the action of micro-organisms 
in the tissues. 

The organisms which surgeons 
have most frequently to contend with 
are those which produce suppuration. 
Of these there are several varieties, 
although the majority of them have 
the globular or coccus form and are 
called "pyogenic cocci." 

The staphylococcus pyogenes au- 
reus was first recognized by Ogston 
and Rosenbach, the latter of whom 
gave it the prefix derived from 
ozayuXr] (a bunch of grapes), owing 
to the characteristic grouping of the 
cocci in clusters (Fig. 6). Its shape 
is globular, and the developed organ- 
ism measures about 0.7// in diam- 
eter. The younger cocci are some- 
what smaller, the size depending to 
a certain extent also upon the nature 
of the soil in which they are grow- 
ing. They multiply by division in 
the manner already described, but 
the line of fission is difficult to see, 
owing to its fineness. They are 
readily stained by all the coloring 
agents, being well adapted to the 
Gram method of staining, and beine 





Fig. 6.— Staphylo- 
coccus Pyogenes 
Aureus. 



one of the varieties of micro-organ- 



Fig. 7. — Staphylo- 
coccus Pyogenes 
Albus. 



isms most easily demonstrated in 
this way. Although no spores are found, the aureus is a very 
durable form of organisrn. Its power of growth is not destroyed 
by drying for ten days. It requires strong chemical substances or 



48 



44 SURGICAL PATHOLOGY AND THERAPEUTICS. 

boiling for several minutes in water to kill it. On gelatin-cultures 
it can preserve its vitality and power of reproduction for a year. 
Becker first obtained growths of the staphylococcus on gelatin, to 
which it had been transferred from the abscesses of cases of osteo- 
myelitis, but Rosenbach was the first to recognize that it was not 
confined to this disease alone, but was common to all forms of sup- 
puration. It grows well at ordinary house-temperatures, but is 
more active when subjected to a temperature of from 30 to 37 C. 
It can develop activity in media which have only a very small 
amount of oxygen. The staphylococcus pyogenes aureus exhibits, 
when grown upon solid culture-media, certain peculiarities which 
distinguish it from all other varieties of cocci. When the gelatin 
is inoculated, a growth of an opaque gray color takes place along 
the whole length of the puncture. At the same time the gelatin 
immediately around the growth begins to liquefy, but more rapidly 
near the surface than lower down. At the end of three or four 
days the surface of the gelatin becomes completely liquefied, and 
the bacterial growth begins to sink as the softening of the gelatin 
proceeds downward. By this time it begins to assume a golden- 
yellow or orange color, and collects in a mass at the bottom of the 
puncture-canal. It has a peculiar odor of sour paste, particularly 
w T hen grown on potato. 

When a culture is made on the surface of obliquely-hardened 
agar there forms along the needle track primarily a moist glisten- 
ing growth, which is at first a yellowish-white, but soon becomes 
an orange color (Fig. 6). The growth is somewhat elevated above 
the surface, is from 3 to 4 mm. wide, and has a wavy border. The 
color may not develop at first, but it appears especially brilliant if 
the growth has not taken place in the high temperatures of the 
oven: in the latter case the luxurious growth appears to interfere 
with the pigment-formation, which occurs most pronouncedly 
when the growth is well exposed to the air. It can be prevented 
from occurring if the air is shut off by a film of sterilized oil or 
by other means. 

The aureus is found abundantly outside the human body. Its 
presence has been demonstrated in dirty dish-water, in the soil, 
and also floating in the air, particularly in foul hospital wards. 
But its commonest seat is the superficial layer of the skin. It 
has been found also in the respiratory and digestive tracts, in 
the normal mucus of the pharynx and the saliva, in the biliary 
ducts and the faeces, and, most important of all for the surgeon to 
remember, in the dirt collected under the ends of his finger-nails. 



SURGICAL BACTERIA. 45 

The liquefaction of the gelatin appears to be due to the presence 
of a soluble peptonizing ferment which is excreted by the aureus. 
It has also the power to peptonize albumin. It has generally been 
supposed that poisonous ptomaines and toxines were not formed 
bv the staphylococci, but recent investigations have shown the 
contrary to be the case. The pathogenic qualities of the cocci of 
suppuration are described in another chapter. The aureus is the 
commonest of all pyogenic cocci, and it has been found in 80 per 
cent, of the cases of suppuration examined. 

Staphylococcus pyogenes albus (Fig. 7) behaves in all respects 
like the aureus, except that it does not develop the golden-colored 
pigment. It appears to 
be a variety of the aureus, *v. ...-' 

but cannot be so culti- \J v.^, #t .•"' '"'}'%"' 

vated as to change into .' V : . \ , '" : ,.\ 

the aureus. It always :* *':).: \J ^ ..["' ••.'.'.'■'■" 

retains its characteristic . t : :•;£'.#•*' \S. \ 

white growth, occurs less •. ..•*"*' '''->.., «... t \ t 

often than the aureus, _ . ,..--.. '•< •': \/ "••••:;.. 

and does not seem quite ' .-l}]-' .>' ?.jj> •„ 

so virulent, as the symp- ••*v. v -"*'" ;'*♦ * '*"'':;'' 

toms caused by it ap- ..«:' .V './ ... ..- A 

pear clinically less pro- *' \ 'S.\ >j " .. '-"y \ 

nounced in severity. : . U.:;' B% \\ (•"•{ 

Staphylococcus viri- '" •'' >'./.' : '' •• *"*""'" 

dis flavesce7lS occupies Fig. 8.— Streptococcus Pyogenes. 

an intermediate posi- 
tion between the aureus and albus (Babes). On agar it forms a 
delicate film. The cocci are irregular in shape, and are larger 
than the aureus. The staphylococcus flavescens is very rare. 

Staphylococcus pyogenes citreus, a variety seen by Passet in two 
cases, appears in all respects similar in its behavior to aureus and 
albus, except that it develops a lemon-yellow pigment. It lique- 
fies gelatin more slowly than the two varieties above named. 

Staphylococcus cereus albus et jlavus are two unimportant varie- 
ties of pyogenic cocci, also described by Passet. The cocci are cha- 
racterized by a dull, waxy growth on the surface of gelatin. They 
cannot be distinguished under the microscope in any way from the 
other varieties. As they are very rare forms, and later observers 
have failed to find them, Baumgarten suggests that it may be 
possible the genuine pyogenic coccus had died out, and that the 
cereus was a remaining form which Passet accidentally observed. 



4 6 



SURGICAL PATHOLOGY AND THERAPEUTICS. 



Micrococcus pyogenes tenuis is a name given by Rosenbach to 
another rare form of pyogenic coccus. It has only been seen once 
since by later observers. Microscopically, the cocci 
are somewhat more irregular in shape and larger 
than those of the aureus. On the surface of agar 
the tenuis forms a very thin, transparent deposit. 
This coccus obtains its name from the great deli- 
cacy of its growth. It is quite possible that this 
variety, like the cereus, was an accidental inhabit- 
ant of an abscess and not the genuine pus-pro- 
ducer. Rosenbach does not place it among the 
staphylococcus group of micrococci. 

The streptococcus pyogenes is one of the most 
important varieties of the pyogenic cocci. It usu- 
ally occurs alone, but sometimes it is found with 
staphylococci, and is microscopically identical with 
the streptococcus of erysipelas. The arrangement 
of the cocci distinguishes it in a marked degree 
from the staphylococcus group. The cocci are 
arranged in rows or chains (Fig. 8), instead of in 
bunches. There are usually from six to ten thus 
attached, and they appear to be grouped, further- 
more, somewhat in couples like the so-called "dip- 
lococci." The individual cocci are small globular 
cells from 0.3/i to 0.4/i in diameter. They grow 
at ordinary house-temperatures, but more actively 
at a temperature of from 30 to 37 ° C. They are 
not particularly sensitive to the absence of oxygen, 
but grow best upon the surface of nutrient media. 
They are easily colored by the different aniline 
dyes, and are adapted to the Gram method of 
double staining. 

In culture-media the cocci grow slowly (Fig. 9); 
in gelatin cultures the small white colonies appear 
throughout the whole length of the puncture. As 
a rule, there is not much growth on the surface, 
the growth reaching nearly its full development in four or five 
days. On agar the growth shows a similar tendency to collect in 
minute globular drops, which finally form a border at the margin 
of the scratch. The color of the points is white, and the growth 
at first has quite a transparent look, but later the centre of the 
colony has a- faintly brownish color. 




Fig. 9. — Strepto- 
coccus Pyogenes 
(culture). 



SURGICAL BACTERIA. 



M 



If it is desirable to obtain a considerable number of these cocci, 
they can be grown very rapidly in bouillon. The streptococci are 
found, in the normal state, in the saliva, in the secretion from the 
nostrils, in vaginal mucus, and also in the urethra. 
Thev are also found wherever the normal condition 
is disturbed by other diseases. We are apt to get 
what is called a "mixed infection" with this or- 
ganism in typhoid fever, diphtheria, pneumonia, 
tuberculosis, scarlet fever, etc., and it is therefore 
probably an important agent in producing compli- 
cations of those diseases. 

Bacillus pyocyanens is an organism found in 
green or blue pus. It occurs, however, only in 
open wounds, and is not, strictly speaking, a pyo- 
genic organism, not usually producing suppuration. 
It is sometimes found in the serous secretions of 
wounds and in the perspiration. It is a small, thin 
rod with distinctly rounded ends, and may occur in 
chains of five or six links. It .has very active 
movements. Spores are not seen to form. It be- 
longs to those organisms which can grow where 
there is a small amount of oxygen, and develops at 
ordinary house- and oven-temperatures. When 
grown in gelatin there develops a shallow bowl-like 
depression, on the border of which there forms a 
beautiful green fluorescent pigment (Fig. 10). The 
depression widens until it reaches the borders of 
the test-tube, and then the greater part of the bac- 
terial growth sinks to the bottom in thick, shining 
bands. The gelatin above gradually clears itself, 
and over the surface is formed a delicate yellowish- 
green film. The whole culture has a distinctly 
greenish tint. The pigment is deposited from the 
bacteria when in contact with oxygen, and it is 
therefore found only on the exposed edges of 
dressings. The substance then formed has been 
named " pyocyanine." According to Frankel, if i c.cm of a 
fresh bouillon culture is injected into the subcutaneous tissue of 
guinea-pigs or of rabbits, a fatal infection is produced. By begin- 
ning with minimum doses only small abscesses will result, the 
animals finally becoming able to bear doses which would otherwise 
be fatal. Its prophylactic character was first discovered by Bou- 




Fig. 10. — Bacillus 
Pyocyaneus. 



48 SURGICAL PATHOLOGY AND THERAPEUTICS. 

chard, who showed that anthrax, even when already developed in 
the animal, could be cured by injection of this bacillus. Another 
variety, described by H. C. Ernst, is supposed by him to possess 
septic qualities, and still another is mentioned by Paul Ernst 
which is non-pathogenic. 

Bacillus pyogenes fcetidus is found, according to Passet, in the 
pus of perirectal abscesses. It forms on the surface of gelatin a 
delicate white or grayish growth. On agar and on potato it has a 
light-brown color and emits an offensive odor. 

Micrococcus tetragenus was first found by Koch in the tuber- 
culous cavity of a lung, and is occasionally seen in morbid and 
healthy expectorations. It was found by Steinhaus in an acute ab- 
scess near the angle of the jaw : under the microscope the charac- 
teristic groups of four were observed enclosed in a capsule, and in 
very large numbers. It was also seen by Iakowski in two cases of 
acute abscess, one on the finger and the other in the palm of the 
hand. In culture-media the cocci do not grow in any special 
order, but in the tissues they are arranged in groups of four 
imbedded in a gelatinous membrane. The organism is aerobic. 
It colors well with all the aniline dyes and by the Gram method. 
On gelatin it appears as thick, globular, whitish masses with a 
somewhat glistening surface. 

Bacillus coli communis (Escherich) was first discovered in 
1885, at which time this micro-organism was reported as being 
constantly found in the discharges of cholera patients at Naples. 
Since then it has been found usually present in the normal dejecta. 
It is also found outside the body, both in air and in water and in 
putrefying fluids. Its presence in diarrhoeal discharges and its 
near relation to the typhoid bacillus caused it to be studied very 
closely in order to find some method by which the two organisms 
could be separated. Lately the importance of this bacillus as a 
pyogenic organism and as a cause of septic and suppurative pro- 
cesses has been fully recognized. 

The bacillus varies in shape with the media in which it is 
grown, and to some extent also with the source from which it 
comes. It is usually seen as a short rod, from 2 to 3// in length 
and from 0.4 to 0.6/i in breadth, with rounded ends. It may 
grow in chains of from four to six filaments, though it is most 
frequently combined in pairs (Fig. 11). Sometimes these various 
forms are associated together, giving the microscopic field the 
appearance of a mixed culture. Spores have not been demon- 
strated, but the organism possesses very numerous and peculiarly 



'K 




<" r 












' 1 K 




* 1 
\ 


H* 




^ ^ - 








7' * 


\ 


^ KV v 


'" v 


</ 


f '< 



SURGICAL BACTERIA. 49 

arranged cilia. It stains readily with any of the watery or 
alcoholic solutions of the aniline dyes, bnt gives np its stain in the 
presence of iodine, and hence is decolorized by the Gram method. 
The products of its growth are acid, as shown by the addition 
of litmus to the culture-media in which it develops. It grows 
freely on both acid and 
alkaline media with or 
without the presence of 
oxygen. It does not 
liquefy gelatin. On plates 
the colonies may have two 
distinct forms — one an ir- ^ 
regular film, rapidly spread- AfT 
ing over the surface with a 
slight opalescent appear- 
ance, and the other an 
ivory-white, heaped-up col- 
ony, Which has 110 tendency Fia n^Bacfflns Coli Communis. 

to spread. In gelatin-tubes 

the bacilli grow along the whole length of the needle track and 
spread out on the surface of the gelatin. Sometimes a moss-like 
growth takes place into the gelatin from the needle track. 

The bacillus coli communis is distinguished from the typhoid 
bacillus by the fact that the latter does not form acid products in 
its growth and has no power to decompose grape-sugar or glucose, 
while the bacillus coli communis rapidly turns blue litmus red, 
and decomposes sugar, with the evolution of a considerable amount 
of gas. A large number of bacilli resembling this organism have 
been found by Jeffries, Booker, and others in the intestines, both in 
health and in disease. The role of greatest importance to the 
surgeon is played by this organism in the production of suppura- 
tive processes in the peritoneal cavity. 

Frankel found it under these conditions more frequently than 
any other organism, and in the majority of cases it appeared as a 
pure culture. Ljvy found pure cultures in the peritoneal fluid and 
in the secondary broncho-pneumonia of two patients who had died 
from strangulated hernia. He also obtained a pure culture from a 
case of abscess of the liver and from a lymphangitis of the arm. 
Richardson found pure cultures in fulminating appendicitis with 
perforation of the appendix. The bacillus has been found also in 
an anal abscess and in the urine of cases of cystitis. 

Bartacci in a recent article shows that in nearly all the cases of 
4 



50 SURGICAL PATHOLOGY AND THERAPEUTICS. 

perforating peritonitis in man and in experimentally produced per- 
foration in animals the bacillus coli communis is the only organism 
to be obtained by culture. Quite a number of other forms of 
bacteria exist in the extravasated fluids, but they do not appear to be 
able to grow in the presence of the bacillus in the ordinary culture- 
media. Bartacci does not, however, assume that the bacillus coli 
communis is therefore alone the cause of the septic peritonitis, but he 
thinks it proper to attribute part of the septic poisoning to the intes- 
tinal gases and faeces and to the various bacteria which they contain. 

Experiments upon animals show that the effect produced by 
inoculation depends upon the source from which the bacilli are 
obtained. If taken from the normal intestine, they have no effect 
upon rabbits nor upon guinea-pigs. If the cultures are obtained 
where diarrhoea or ulceration is found, then the bouillon culture 
introduced into the peritoneum produces septic peritonitis or, in 
smaller doses beneath the skin, suppuration. Cultures which were 
violently septic have been found, on exposure, to become pyogen- 
ic. When, therefore, the soil on which it grows is modified by an 
intestinal lesion, this organism assumes a virulent condition, and if 
it can make its way into the peritoneal cavity or into any organ of 
the body, it is capable of setting up septic or suppurative processes 
of a greater or lesser degree of intensity. 

Under favorable conditions other organisms may assume pyo- 
genic qualities, such as the typhoid bacillus and the pneumococcus. 

T\iz gonococcus was first discovered in 1879 by Neisser, and sub- 
sequent investigation has sustained the conclusion that it is the 
specific organism which produces gonorrhoea. It is a compara- 
tively large micrococcus, measuring 1.25/* in diameter, and is 
usually arranged as a diplococcus. 

One of the most striking peculiarities of the gonococci, however, 
is the fact that they are accustomed to penetrate the protoplasm of, 
and to multiply rapidly in, the pus-cells. The nucleus of the cells 
is not touched by them. This characteristic grouping distinguishes 
them from nearly all other forms of micrococci. It is indeed very 
rare to see any gonococci outside the pus-cells. A cell may be so 
filled with them as to lose all its characteristic structure and appear 
only as a clump of cocci. The relation of the bacteria to the pus- 
corpuscles is regarded by some as evidence of its activity, by others 
as an illustration of the protective action of the phagocytes. 

The gonococci are stained well with methyl-blue. They do not 
adapt themselves to the Gram method, as the iodide of potassium 
deprives them of their color. Neisser recommends the following 




SURGICAL BACTERIA. 51 

method : A cover-glass having been prepared with a layer of the 
fluid to be examined in the usual way, it is treated for a few 
minutes with a concentrated alcoholic solution of eosin, the 
action of which is reinforced by heat. The excess of eosin 
being removed by blotting-paper, a concentrated alcoholic solu- 
tion of methyl-blue is next applied for fifteen seconds, and then 
washed off with distilled water. The cocci are now seen colored 
blue, while the protoplasm of the leucocytes is stained a delicate 
pink and their nuclei blue (Fig. 12). 

The gonococci do not grow on any of the ordinary culture- 
media, such as gelatin or agar or potatoes. Even on the media on 
which they do develop they are so 
frequently mixed up with other 
forms that the latter grow rapidly 

and present appearances which ' *«^*„ ~* % ^eg •§*•" >* 

make it difficult to distinguish 
them from the genuine gonococci. 

Bumm has succeeded, however, 
in making them grow on human ** - ;. y>--' 

blood-serum, but this growth is ** % *j 

accomplished with considerable \a '•■:* - , * \ 

difficulty. The materials used " V. v 

must, in the first place, be as free ^ .y** 

as possible from other organisms, ,-> '" - >s V>f 

otherwise the latter will outgrow 

the COCCUS. The gonorrheal pUS, Fig. 12.— Gonococci. 

containing the organism in large 

numbers, must be placed on the surface of the blood-serum in 
drops of considerable size. Scratch- or stab-cultures are of no 
value. The test-tube must be placed in an oven at a tempera- 
ture of from 33 to 37 ° C. The growth forms a delicate film 
with, well-defined, irregular borders. It appears like a layer 
of varnish upon the top of the serum. When somewhat thicker 
it has a grayish-white or a slightly brownish tinge. The growth 
is slow and scant in amount. At the end of two or three days the 
cocci begin to die off, and the culture must therefore be often trans- 
planted if it is desired to preserve the organisms. As nothing 
further will be said about this disease, it may be well to study here 
the action of the gonococci in the human epithelium. 

For some time it was thought that sufficient proof had not been 
afforded of the specific character of the gonococcus. There is no 
one single characteristic which distinguishes this organism from all 



52 SURGICAL PATHOLOGY AND THERAPEUTICS. 

others, but the combination of peculiarities which have just been 
mentioned is such as is not found in other forms of bacteria. 
These peculiarities are — the diplococcus or " breakfast-roll " shape, 
the characteristic arrangement of the organism in the pus-cells, 
the bleaching caused by Gram's solution of iodide of potassium, 
and the difficulty of cultivation on ordinary media. 

Proof positive has been afforded, however, by several experi- 
menters of its contagious character. Bumm transplanted the 
twentieth generation of a gonococcus culture to the urethra of a 
bedridden paralytic, and produced a typical gonorrhoea. This 
experiment has recently been made upon the healthy urethrae of 
medical students. Bumm also examined the different stages of the 
gonorrhceal inflammation in the conjunctiva of new-born infants. 
Twenty-six fragments were taken from the conjunctival mem- 
brane at periods of the disease varying from thirty-six hours to 
thirty-two days. He found that the cocci, once having entered 
the conjunctival sac, reproduce themselves rapidly in the secre- 
tions, next invade the epithelial layer, and finally force their way 
down to the papillary layer. On the second day an enormous 
immigration of leucocytes takes place into the invaded layer of 
epithelium and the surrounding cells, pushing the epithelial cells, 
so as to lift them from their bed. On the papillary layer thus 
exposed there forms an exudation of a fibro-cellular character in 
which are clumps and rows of growing cocci. The bacterial 
growth does not invade the deeper tissue ; it does not go beyond 
the most superficial of the sub-epithelial layers. A regeneration 
of the epithelium soon covers over the denuded spots, and the 
cocci, after growing for some time longer on the surface, gradually 
disappear. It is only on certain types of mucous membrane that 
these organisms will grow — namely, those which possess a cylin- 
der epithelium or one closely allied to it. These are the mem- 
branes of the male and female urethra, the uterus, Bartholin's 
glands, and the conjunctiva. The more deep-seated secondary 
inflammations, such as involve the prostate, the epididymis, the 
testicles, the uterus, and the tubes, are frequently due to the pres- 
ence of some of the pyogenic bacteria ; but suppurative inflamma- 
tion of both tubes and ovaries has been found to be due largely to 
the presence of the gonococcus. The aureus has been found as a 
frequent companion of the gonococcus in the urethral discharge 
and in the pus from gonorrhceal buboes. The metastatic inflamma- 
tion of joints and the endocarditis which occur as sequelae of 
gonorrhoea have been supposed to be due to the presence of 



SURGICAL BACTERIA. 53 

pyogenic cocci, but Councilman and others have shown that the 
gonococcus may be the sole organism concerned in the inflamma- 
tory process. 

Why the gonococcus should grow only in the superficial layers 
of certain mucous membranes, and nowhere else in the body, 
has not yet been satisfactorily explained. The most plausible 
theory seems to be that inasmuch as the gonococci possess a very 
marked preference for oxygen, they find a better culture-soil in the 
epithelium than in the subjacent connective tissue. Bumm has 
shown that injections of pure gonorrhoeal discharge or of pure 
cultures of the gonococcus into the subcutaneous tissue do not 
produce suppuration. That this loss of activity is not explained 
by the action of phagocytes is shown by the fact that the organ- 
isms, when the tissues are examined later, are not taken up by 
the cells of the part, but are nearly all to be found outside the 
leucocytes. 

After the gonococci have existed for a certain length of time in 
the epithelium of the part, they disappear spontaneously in a 
certain number of cases. This disappearance is accounted for by 
the casting off of the cylinder epithelium during the inflammatory 
processes, and its replacement by a pavement epithelium which 
resists the efforts of the cocci to penetrate it. In this way proper 
nutriment gradually fails them and they die out. It is generally 
accepted that cure is effected in this way rather than by the phago- 
cytes, for such leucocytes as are invaded by the gonococci are 
destroyed by the latter during the active growth and multiplication 
of the organisms which take place in the protoplasm of those cells. 

Streptococcus erysipelatis in all respects so closely resembles 
the streptococcus pyogenes that the majority of bacteriologists are 
unable to detect any constant differences between them either by 
the microscope or by culture. The description of the organism 
coincides with that already given to the streptococcus : therefore it 
is needless to repeat it here. Rosenbach undertakes to recognize 
certain distinguishing marks between the two. He thinks the 
cocci and the chains of the erysipelas coccus are larger than those 
of the pyogenic coccus. His delineations of the culture show a 
growth of the erysipelas coccus more transparent and more 
irregular and nodular in outline than is seen in the cultures of the 
other organisms. The brownish tint of the culture is also want- 
ing. The weight of evidence at the present time is, however, in 
favor of the identity of the two organisms. The question is dis- 
cussed more at length in the chapter on Erysipelas. 



54 SURGICAL PATHOLOGY AND THERAPEUTICS. 

Bacillus Tetani. — The first observations on the nature and origin 
of this organism were made in 1884 by Nicolaier, who found a 
bacillus in garden soil, and who succeeded in producing tetanus 
in mice, guinea-pigs, and rabbits by injecting the soil into them 
subcutaneously. The same organisms were found in the diseased 
animals, but there was great difficulty in obtaining a pure culture 
of the bacilli, thus giving conclusive evidence of its power to 
produce the disease. This culture was finally accomplished in 
1889 by Kitasato, who planted on a suitable culture-soil a frag- 
ment of tissue from the neighborhood of a wound in a man 
dead of the disease. He found that the spores of this bacillus 
germinated before those of the other forms of bacilli mixed with 
it. As soon as these spores had formed he subjected the culture 
to a temperature of 8o° C. , which killed off all bacteria ; con- 
sequently, the spores of the tetanus bacillus alone, remained, and 
a pure culture of this organism was obtained as soon as the bacilli 
had developed from them. The spores are found in garden soil, 
in masonry, in decomposing liquids, and in manure. 

The tetanus bacillus is a large slender rod with somewhat 
rounded ends. It resembles the bacillus of mouse septicaemia, but 



•v 



1 ^ 1 / 1^ 






X! 



Fig. 13. — Bacillus Tetani. 

is longer: in fact, it sometimes grows into long chains which show 
very imperfectly the lines of division. The spore-formation takes 
place at the end of the bacillus, and, as it enlarges the cell 
considerably, gives it a "pin" or "drumstick" shape (Fig. 13). 
The spore germinates at a temperature of 37. 5 ° C. in thirty hours; 
in the temperature of a house, in about a week. It is motile, and 
belongs to the strictly anaerobic organisms, rapidly dying when 
exposed to the air. It is readily colored by methyl-blue and 



SURGICAL BACTERIA, 



55 



fuchsin, and is brought out very perfectly by the Gram method. 
It can be cultivated in gelatin mixed with grape-sugar, which aids 
in its rapid development. The upper portions of the gelatin 
remain sterile, but in the lower portions of the puncture there is 
an active bacterial growth which sends out innumerable little pro- 
longations, giving to the culture the appearance of an inverted fir 
tree. After the first week the gelatin begins to liquefy and to 
obscure the peculiar features of the growth, until, finally, the 
gelatin is changed into a whitish-gray, tenacious, shining mass. 
To obtain cultures of the tetanus bacillus from cases of trau- 
matic tetanus in man or from experiment animals the following 
method may be employed, which is a modification by Frothingham 
of Kitasato's method : 

Inoculate tubes of decidedly alkaline bouillon with pus from the wound or 
point of inoculation. If there is no pus, small fragments of tissue are snipped 
from the region of the wound and used for this purpose. The tubes should 
now be placed in an atmosphere of hydrogen at a temperature of from 37° to 
39 C. At the end of forty eight hours a microscopic examination may be 
made, and if the tetanus bacilli are found, the tubes are to be heated for 
three-quarters of an hour to one hour in a water-bath previously heated to 
8o° C. From these heated tubes fresh alkaline bouillon may be inoculated. 




Fig. 14. — Hydrogen Jar for Anaerobic Cultures. The stop-cock on the right allows the 
air to escape from the jar, while the hydrogen is passed in from the left. 



These fresh cultures may be allowed to develop under hydrogen at a temper- 
ature of 37 C. for forty eight hours (Fig 14). Pure cultures should be obtained 
in this way, the purity of the culture being verified by microscopic examina- 
tion and growth on solid culture-media, and the virulence being determined 
by inoculation experiments. 

Brieger has obtained from cultures a toxine which he named 
"tetanin," and in addition " tetanotoxin " and "spasmotoxin," 
all of which, when injected into animals, produce convulsive 
movements and, finally, paralysis. Inasmuch as the same group 



56 SURGICAL PATHOLOGY AND THERAPEUTICS. 

of symptoms were obtained by the toxines as were obtained by the 
bacilli, and as the latter are hard to find in the blood and internal 
organs of individuals affected with tetanus, it has been thought 
probable that the symptoms of the disease are largely produced by 
these chemical substances. 

Although Rosenbach and Shakspeare have stated that the 
bacilli are to be seen in the central nervous system, subsequent 
observers have not been able to find them, and it is probable, there- 
fore, that the convulsions are produced by the tetanin elaborated 
by these organisms. 

Bacillus Tuberculosis. — Although experiments were made as 
early as 1865 by Villemin to prove the inoculability of tubercle, 
and as Cohnheim in the following decade decided that tuberculosis 
was a specific infectious disease, it was not until 1882 that Baum- 
garten and Koch simultaneously discovered the organism which 
causes the disease. Baumgarten should receive credit for first 
having seen the bacillus with the microscope, but it remained for 
Koch to cultivate it successfully and by inoculation to prove beyond 
question its right to be considered the cause and only cause of 
tuberculosis. 

The tubercle bacilli are small and thin rods about 2 to 4// in 
length ; that is, about one-quarter to three-quarters the length of 
the diameter of a red blood-corpuscle. The ends of the rods are 
generally slightly rounded, and are usually slightly bent near the 
middle or are more or less curved. In artificial cultures the rods 
are a little smaller than when growing in the tissues. The longest 
rods are usually seen in phthisical sputa. They are generally 
single, occasionally being found in pairs arranged like a V, and 
sometimes several are strung together. They do not possess the 
power of motion. Whether spore-formation takes place is unde- 
termined, although Baumgarten thinks it highly probable that 
it does occur, as a cheesy material, in which it is impossible to 
demonstrate the bacilli by any method of staining, when inocu- 
lated into animals produces the disease. Free spores have never 
been seen, nor have the bacilli been observed in the act of spore- 
formation. In the fresh state none of those bright, glistening 
spots are seen which are characteristic of spores. When colored, 
the bacilli exhibit, placed in regular order, bright spots which are 
very suggestive of spores. The expectorations can be kept months, 
and even years, in a dried state without destroying the vitality of 
the bacilli. The acids of the stomach and the products of decom- 
position have no effect upon them. Pure cultures of bacilli have 



SURGICAL BACTERIA. 57 

been mixed with the food of animals, and have thus been passed 
through the digestive tract without any effect upon their vitality. 
This durability seems to be due to the unusually tough cell-wall 
which the bacillus possesses. The organism is a facultative 
anaerobic ; that is, it may grow without oxygen, although it pre- 
fers to grow with oxygen. 

This is one of the few bacteria which have a pathognomonic 
stain. Though taking the ordinary watery and alcoholic aniline 
stains with difficulty, yet when properly stained it does not give 
up its coloring material even in the presence of mineral acids — a 
property which the bacillus of leprosy alone holds in common with 
it. 

The following is a convenient method (Ziehl) of examining the 
sputa : 

The sputum selected is spread out upon a glass with a dark background to 
enable one to detect the various details, such as the fragments of the diseased 
lung, the secretions of the upper air-passages, and the saliva. The bacilli 
are usually found in the lung-fragments, which are small, tough, yellow 
clumps floating in the saliva. One of these clumps is removed by the steril- 
ized platinum needle and placed upon a cover ; a second cover-glass is then 
placed upon the first, and the specimen is gently pressed between the two so 
as to form a thin layer, whereupon the glasses are separated by a sliding 
motion and are allowed to dry in the air. To complete this process the glass 
to be stained is rapidly passed three times through a flame. A few drops of 
carbolic fuchsin 1 are allowed to trickle over the glass, and it is held over the 
flame until the coloring fluid partially evaporates. More staining fluid is 
now added, and the heating repeated until a satisfactory coloring is obtained, 
or the coloring fluid containing the specimen can be placed in a watch-glass 
and heated for a few moments over a water-bath. The specimen is then 
washed with distilled water. To decolorize the surrounding cells and other 
forms of bacteria a strong decolorizing agent must be used, as, for example, 
a 5 to 10 per cent, solution of sulphuric acid. The glass is moved up and 
down in this solution until the deep-red color becomes a yellowish brown. 
Next place the glass in 70 per cent, alcohol to wash out the dissolved fuchsin. 
Wash with distilled water and color again with ordinary watery solution of 
methyl-blue. Wash, finally, with distilled water and examine, wet or dry, 
the specimen, and mount it permanently in Canada balsam. 

The specimen is examined to the best advantage when wet, as 
the bacilli are not so much shrivelled as when mounted in Canada 
balsam. The tubercle bacilli will be found colored red, and any 
other bacteria which happen to be present, and which have been 
deprived of their red color by the acid, are stained blue, so that 
the different kinds can thus readily be distinguished from one 
another (Figs. 15, 16). The method may be simplified by dipping 

1 Fuchsin 10 parts in 100 parts of a saturated aqueous solution of carbolic acid. 



58 SURGICAL PATHOLOGY AND THERAPEUTICS. 

the red-colored specimens into a solution in which the acid and 



?4 






% 









S 



.4fc 



% 



# 



Fig. 15. — Tuberculous Sputum. 

the methyl-blue are both present: water, 50 parts, alcohol 30 
parts, nitric acid 20 parts, and methyl-blue to saturation. This 



* 
* WW 







" 






m 



s* 



1 % 



Fig. 16. — Tuberculous Urine. 



simplifies the process somewhat. Sections are colored very much 
in the same way: 

Place the section for half an hour in a dish of carbolic fnchsin ; allow it 
to float for one minute in a 5 per cent, solution of sulphuric acid ; wash in 60 
per cent, alcohol. Next stain with methyl-blue for two or three minutes. 
Wash in water and weak alcohol, dehydrate in absolute alcohol, and, having 
cleared it in oil of cedar, mount in Canada balsam. 



SURGICAL BACTERIA. 59 

Although for clinical work the short methods may be used in the 
hands of experts, still it must be remembered that the Ziehl 
solution stains a number of spores, which, unless recognized, 
may prove a source of error. It is not generally known that 
under certain conditions — for example, age — the bacilli may not 
be stained by the quick methods. When stained for twenty- 
four hours according to the now nearly-forgotten Koch-Ehrlich 
method the bacilli are well defined. For this reason the Koch- 
Ehrlich method is given. It should however, be remembered that 
this method shows crystalline forms which may be mistaken for 
bacilli: 

Place the section in aniline-water fuchsin for twenty-fonr hours ; decolor- 
ize in a 25 per cent, solution of nitric acid ; wash in 60 per cent, alcohol ; 
place in watery methyl-blue for a few moments ; wash and mount. 

Under the microscope is seen the miliary tubercle consisting of 
leucocytes and epithelial cells, and a giant-cell in or near the 
centre of the growth. The bacilli are found lying in small 
numbers between the leucocytes and in the giant-cell. The nuclei 
of the giant-cell appear to be arranged in a radiating manner at its 
periphery, as do also the bacilli. This arrangement is due to the 
fact that the centre of the cell has undergone degeneration and its 
contents at this part have disappeared. This appearance is quite 
characteristic of the tubercular giant-cell, and distinguishes it 
from the giant-cell of sarcoma (Fig. j6). The degenerative pro- 
cess is seen also in the other cells at the centre of the tubercle, 
while new cells and bacilli are seen on the borders. In this way 
the growing tubercle undergoes a cheesy degeneration at its 
centre. If the disease at this stage is on the surface of the skin or 
a membrane, ulceration will occur. 

The growth of the organisms is exceedingly slow, and takes 
place at the temperature of the human body, and very slight 
deviations from this point are likely to arrest their development. 

Koch devised expressly for this organism the hardened blood- 
serum. Nocard and Roux have suggested a combination of agar 
with glycerin, upon which it grows even better, as the bacillus 
seems to have a predilection for glycerin, and this being also 
much more easily sterilized. When cultivated in the test-tube on 
agar thus prepared, a well-developed growth is procured at the end 
of fourteen days, while on blood-serum from one to two weeks 
more must pass before the culture reaches the same point. It then 
appears as thick crusts of a dull grayish-white color, which crusts 



6o 



SURGICAL PATHOLOGY AND THERAPEUTICS. 



are very dry and brittle and are made up of minute scale-like 
masses (Fig. 17). If the growth meets a drop of condensed moist- 
ure, it will form a thin film over the latter, without 
in the least disturbing the clearness of the fluid. 

To obtain materials with which to make a series 
of pure cultures tuberculous sputa may be injected 
into a guinea-pig. When tuberculosis is established, 
the animal should be killed, and a fragment of tu- 
bercle taken, with due precautions, from the lung 
and placed upon the culture-soil. After develop- 
ment takes place the fragment of lung can be seen 
under a low power, and surrounding it are seen 
S-shaped, wavy, and scroll-like masses of bacilli. 

The tubercle bacillus is not found growing out- 
side the living tissues of man and animals, the 
necessary conditions of nutrition and temperature 
not existing elsewhere. They must be regarded, 
therefore, as true parasitic organisms. Although 
they are unable to grow around us, their great power 
of resistance permits of their being preserved for a 
long time in a dried state mixed with dust, and of 
taking on an active growth whenever an opportunity 
occurs for them to become grafted again upon the 
living tissues. 

This inoculation may take place on the skin fol- 
lowing slight blows or bruises or cuts. The hands 
of attendants on the sick may be cut with a glass 
containing sputa. Anatomical tubercle is an exam- 
ple of this form of contagion. The disease known 
as "lupus" is but a variety of tuberculosis of the 
skin. As has been seen, the bacillus is extremely 
resistant to the action of the digestive fluids, and 
animals experimentally fed with this organism have 
succumbed to a general tuberculosis. Whether in- 
oculation can take place through the uninjured mu- 
cous membrane has not been demonstrated, but it is 
probable that if bacteria can penetrate the uninjured skin, they can 
also work their way through a normal mucous membrane. As a 
rule, the mesenteric glands are found first affected, and afterward 
the mucous membrane — a sequence which is at least suggestive that 
the membrane was previously in a healthy condition. Later, the 
spleen and liver are found infected. A very practical deduction from 




Fig. 17 — Bacillus 
of Tuberculosis 
on glycerin- 
agar. 



SURGICAL BACTERIA. 61 

these experiments is the necessity for the supervision of food, par- 
ticularly the milk of tuberculous cows. It is now well known that 
the organisms are found in the milk. H. C. Ernst has shown that 
six drops of infected milk injected subcutaneously into a guinea- 
pig will produce a general tuberculosis even though there be no 
manifestations of disease in the udder. 

The question of an infection through the respiratory tract 
appears to be a disputed one. According to Baumgarten, experi- 
mental work seems to point against such mode of entrance into the 
system. Frankel, who writes with the authority of Koch behind 
him, takes the opposite view, and believes that breathing infected 
air is the most frequent mode of acquiring the disease. Experi- 
ment shows that the disease appears first at the point of infection, 
and therefore is at first local. The frequency of the disease in the 
lungs surely points strongly to the respiratory tract as the route 
through which infection takes place. Inasmuch as it has been 
proved that bacilli can float in the air when dry, it is probable that 
they are in this way conveyed from one individual to another. 
The durability of the organism, as already seen, protects it from 
the injurious influences of desiccation. As Stone has shown, it 
may retain its vitality in this condition for three years. How this 
transfer may take place has been explained by the investigations 
of Cornet. He demonstrated that the organisms are not found 
distributed indiscriminately in the air and other surroundings, but 
that they are found only in localities frequented by tuberculous 
patients, in such places as one would expect to find their expec- 
torations. This he demonstrated by injecting the dust of infected 
localities into guinea-pigs, thus producing the disease. The dust 
of other localities produced negative results. The bacilli are 
therefore frequently found in houses inhabited by tuberculous 
individuals. The organisms, having been expectorated on the 
floor or on handkerchiefs, are subsequently disseminated through 
the building in the form of dust. Cornet regards with suspicion 
hotels or hospitals occupied by consumptives, and the same may- 
be said of factories, prisons, or other buildings where large 
numbers of individuals are congregated. Cornet strongly advises 
that tuberculous sputa should not be allowed to dry up, but should 
be kept in a moist state. 

Bacillus mallei (bacillus of glanders ; rotz bacillus ; morve). — 
This organism was discovered by Loffler and Schutz, who made 
rheir announcement in 1882. They demonstrated the presence of 
the bacilli in the diseased tissues, cultivated them outside the living 



62 SURGICAL PATHOLOGY AND THERAPEUTICS. 

organism, and inoculated them successfully into animals, thus 
reproducing the disease. These organisms are somewhat shorter 
than, and not quite so thin as, the tubercle bacilli ; that is, in 
length they are about two-thirds the diameter of a red blood-cor- 
puscle. They are frequently arranged in couples, side by side, but 
generally are single. In culture several of them may be linked 
together in a chain (Fig 18) ; in the tissues they are distributed in 
clusters, either parallel with one another or pointing in various 
directions. They possess no movements of their own. The pres- 



a 



tip 



«o 






vss^J-xv 












>*}K 



Fig. i 8. — Bacillus Mallei. 

ence of spores has been doubted, and the peculiar bright spots seen 
when the bacilli are colored are not spores, but are evidences rather 
of a degenerative change. Baumgarten has, however, by a special 
method of staining, been able to show that in some cases at least 
they are able to form spores. He does not think, however, the 
spore-formation takes place in the living tissue. The durability 
of the glanders bacilli is not, however, apparently great ; they do 
not bear desiccation more than two or three weeks ; exceptionally 
they may last as long as three months. The so-called " spontane- 
ous glanders " which occurs at long intervals after the existence 
of a local epidemic may be explained possibly by the presence of 
spores. They belong to the facultative-anaerobic bacteria, and 
grow best at a temperature of from 30 to 40 C. They belong to 
that class of bacteria which takes the staining fluid easily, but they 



SURGICAL BACTERIA. 63 

as readily lose their color. One of the simplest methods of stain- 
ing is to treat a cover-glass preparation with warm carbolic fnchsin, 
and to wash off with a 2 per cent, solution of nitric acid. No 
method of double staining has yet been successful. In staining 
sections they should be placed six to eight hours in carbolic 
methyl-blue, then in acetic-acid solution, and finally in distilled 
water. Having been dried on the object-glass with a current of 
air, they are cleaned in xylol and mounted in Canada balsam. 

The bacilli can be grown upon a 4 per cent, glycerin-agar. 
When cultivated upon this soil, hardened obliquely in a test-tube 
at a temperature of 37 C, they form on the fourth or fifth day a 
white, transparent, moist, glistening film along the needle track. 
The growth on potato is very characteristic, it forming here a yel- 
low, transparent, honey-like layer which appears on the second day. 
In a few days it becomes deepened in hue and less transparent. 
For a short distance around the border of the culture the potato 
acquires a yellowish-green color. No other organism presents these 
appearances under cultivation. When seen in sections under the 
microscope, the bacilli are found singly or in small groups, the 
latter evidently having developed in a cell which has subsequently 
broken up. The capillary vessels do not seem to be involved, a 
fact which corresponds with their rare occurrence in the circulation. 
The greatest collection of bacilli is in the centre of the nodule or 
tubercle — a condition which is almost as characteristic of glanders 
as it is of tuberculosis. As the border is approached few organisms 
are found. The majority of the bacilli lie between the cells. The 
principal cells of the nodule are the epithelioid cells ; giant-cells 
are never seen. As the nodule develops leucocytes abound. The 
pathological changes which follow resemble the softening of sup- 
puration. The process seems to stand midway between the cheesy 
degeneration of tubercle and the suppuration produced by the 
pyogenic cocci. Very few of the organisms are found in the 
secretions from the nostrils. It has been found that the bacilli 
readily lose their virulence after several generations of culture have 
been reached, and this points to the fact that, outside the living 
organisms, the conditions are unfavorable for their preservation. 
The bacillus mallei probably does not grow out of the living tissues 
except under very favorable circumstances, it being for the most 
part a true parasite. 

The virus can readily be inoculated into horses, and the disease 
with all its characteristic symptoms may thus be reproduced. 
Asses are also susceptible to glanders, as are goats, cats, field-mice, 



64 SURGICAL PATHOLOGY AND THERAPEUTICS. 

and guinea-pigs. Pigs, white mice and house-mice, and oxen, 
however, possess a certain immunity. Lions and tigers have suc- 
cumbed to the disease by infection experimentally produced by 
mixing the virus with their food. The virus acts first at the point 
of inoculation, and thence spreads slowly throughout the tissues, 
the blood remaining almost entirely free from bacilli. At the 
post-mortem examination nodules are found in the spleen, the 
liver, or the lungs. 

In examining a glanders nodule which has not yet broken down 
one is generally able to discover the bacilli in colored sections ; but 
it is well at the same* time to make a potato-culture, which will, 
if the bacilli are present, show the characteristic growths. 

If it is desired to examine the nasal secretions or discharges 
from ulcers, a satisfactory result will not be obtained by the above 
methods, for here the bacilli are not numerous, and are mingled 
with different kinds of bacteria which resemble them. This dif- 
ficulty is overcome by inoculating guinea-pigs with the material to 
be tested. Field-mice, which are otherwise suitable for inocula- 
tion, are liable to die of septicaemia. If the bacillus mallei be 
present, it will be found in the nodules that develop with the 
disease. 

Bacillus of Leprosy. — A few words on this organism are appro- 
priate in this chapter, as leprosy is a disease closely allied to tuber- 
culosis, and its organism bears points of resemblance both to the 
tubercle and to the glanders bacillus. The disease is one which 
also occasionally comes to the surgeon for operation. This bacillus 
was first described in 1880 by Hansen, whose work was later con- 
tinued by Neisser, a skilled bacteriologist. The bacilli of leprosy 
in appearance are almost exactly like the tubercle bacilli. They 
are long and slender rods with somewhat sharpened ends, and are, 
like the tubercle bacilli, without power of motion. It is doubtful 
also whether the clear tin colored portions seen in the bacilli after 
staining are or are not spores. As has already been shown, they 
are the only organisms which react in the same way as do the 
tubercle bacilli to coloring reagents, which, however, they take 
somewhat more readily. The readiness with which the bacilli 
are stained by the ordinary aqueous and weak alcoholic solutions 
of the aniline colors and also by the Gram method serves to distin- 
guish them from the tubercle bacilli. 

Although the bacillus of leprosy is found in all cases of the 
disease, it is not fully identified as the cause of the disease, it 
being impossible to obtain reliable cultures by any of the known 



SURGICAL BACTERIA. 65 

methods. Inoculations by Bordoni of animals with the bacillus 
have been, without exceptions, failures, which Bordoni explains 
by the rapid weakening of the bacillus when removed from the 
body. Melcher and Ortmann placed fragments of nodules from a 
patient immediately in the anterior chamber of the eye of a rabbit, 
and observed the animal die of the disease several months later. 
At the autopsy small nodules were found in the internal organs, 
and the presence of the bacilli was demonstrated in them. Arning 
inoculated a condemned criminal in the Sandwich Islands with 
material cut from a leper. Some months later a nodule appeared 
at the point of inoculation, and at the end of five years his death 
took place, general leprosy having developed. 

The bacilli are ordinarily found in the skin and the tissue sur- 
rounding the nerves, and in the lymphatic glands, the spleen, and 
the liver, but they are rarely found in the blood. Their tendency 
is to grow in clusters, appearing usually inside of cells, some of 
which are epithelioid in character, and others apparently are 
leucocytes. These cells have been called i{ lepra-cells " by the 
Germans, but some observers denied the existence of such cells, 
and claimed they were merely clusters of bacilli lodged in dilated 
lymphatic vessels. Such clusters form a characteristic appearance 
in discharges from lepra sores. 

Syphilis Bacillus. — The question of the microbic origin of 
syphilis has been extensively discussed and investigated, but as 
yet no definite conclusions have been reached which are generally 
accepted by bacteriologists. 

The most important contribution to this study was made by 
Lustgarten, who in 1884 announced that he had discovered in the 
tissues and in the discharges from syphilitic ulcers a bacillus 
closely resembling the tubercle bacillus, but distinguished from 
other forms by its peculiar method of staining. The bacillus of 
syphilis usually is slightly curved or S-shaped. 

To color it a section should be placed for from twelve to twenty-four hours 
(at the ordinary room-temperature ) in a solution of aniline-gentian-violet, 
and for two hours be kept at a temperature of 40 C, and then placed in 
absolute alcohol for a few minutes ; next placed for ten seconds in a 1 per 
cent, watery solution of permanganate of potash, then for a moment in a 
strong watery solution of sulphuric acid, and finally washed out in distilled 
water. If sufficiently decolorized, it may then be mounted in the usual way. 
The same method may be used for the cover-glass preparation, except that 
water should be used instead of the absolute alcohol after staining, and the 
other steps of the process should follow one another more rapidly. 

A simpler method is to keep the cover-glass in a hot solution of fuchsin 



66 SURGICAL PATHOLOGY AND THERAPEUTICS. 

for a few minutes, leaving sections for twenty-four hours in a cool solution, 
and then bleached in at first a weak and afterward in a concentrated solution 
of chloride of iron. Cover-glasses are washed in water and the sections in 
alcohol. 

The bacilli of syphilis are found always enclosed within large 
cells. Iyustgarten maintains that he has found these organisms 
in all cases of syphilis examined by him, but those who have 
carried out his methods have been unable co find them. They 
have been seen oftener in the cover-glass preparations than in the 
sections. Glanders and tubercle bacilli are stained also by Lust- 
garten's method, but .his syphilis bacilli appear to lose their color 
more easily. Lustgarten's attempts to cultivate these bacilli were 
not successful. They are said to have been grown upon a gelatin 
prepared from the bladder of Russian sturgeon. Transplantation 
of a fragment of tissue on gelatin left at the ordinary house- 
temperature produced a grayish-yellow growth around the frag- 
ment at the end of thirty-seven days. Inoculation was made also 
with the blood of an infected monkey, and the brownish growth 
produced was seen, on examination, to be composed of small 
bacilli. Granules were found also in the cultures which were 
thought to be' spores. 

In 1885 a discovery was made which threw a great deal of 
doubt upon the genuine nature of the syphilis bacillus. Two 
observers simultaneously demonstrated a bacillus in the preputial 
and vulvar smegma bearing a striking resemblance to Lustgarten's 
bacillus. Its appearance and reaction to staining were the same. 
The smegma bacilli were supposed to lose color a little more 
rapidly than the other form, but this difference does not appear to 
be constant. The only variation between the two forms is that, 
while both could be found in discharges from the vulvar or the 
preputial sores, or, possibly, also elsewhere in ulcerations of the 
surface of the body, the smegma bacilli could not be found 
imbedded in the tissues. Many authorities of note are inclined to 
think that some relation exists between these organisms and 
syphilis. 

But this is not the only organism which has been reported as 
the cause of the disease. Eve and Lingard described a bacillus 
cultivated from the blood and the diseased tissues in syphilis. It 
resembles the tubercle bacillus, but it is stained by the ordinary 
aniline dyes and by the Gram method, Lustgarten's method yield- 
ing negative results. A pure culture was obtained by inoculating 
hardened blood-serum with the blood or weak fragments of tissues 



SURGICAL BACTERIA, 67 

from syphilitic patients. The growth appeared as a thin, light- 
yellow or greenish layer. Inoculation of monkeys from this 
culture were not successful. 

Disse and Taguchi examined the blood of patients with sec- 
ondary syphilis, and they almost constantly found cocci i/i in 
diameter, isolated or in colonies, between the corpuscles. The 
cultures upon the different media appeared as grayish-white masses, 
and all culture-media except serum were liquefied by them. This 
is, according to some, the only organism which liquefies agar- 
agar. Gram's method of staining yielded good results. The 
most important claim of these organisms to be regarded as the 
cause of syphilis was the inoculation of rabbits, dogs, and sheep, 
and the production of a chronic infectious disease which was 
transmitted to embryos developed before and after the inoculation. 

Inoculation of animals with the discharges of the diseased tissue 
of syphilitic patients has not always been attended with positive 
results. Klebs successfully inoculated monkeys with the liquid 
obtained from an excised chancre, in which liquid he had found 
bacilli. He made a culture in liquid gelatin and inoculated the 
culture-fluid. Buccal ulcerations developed in appearance some- 
what like plaques muqueses. Caseous deposits resembling gummata 
were found in the dura mater. He also implanted a fragment of 
a chancre beneath the skin, and obtained caseous deposits, which, 
however, resembled tubercle. 

Martineau and Hammic placed in culture-bouillon fragments 
of chancres, and subsequently found a growth of bacilli. They 
obtained, by inoculating monkeys w 7 ith this fluid, eruptions re- 
sembling those of syphilis. An inoculation of the prepuce in three 
places was followed, twenty-eight days afterward, by the develop- 
ment of nodules which resembled indurated chancres. Secondary 
symptoms were also developed. 

Although no satisfactory demonstration has been made, it seems 
highly probable that syphilis is of bacterial origin and that the 
organism is a bacillus ; but the necessary identification by culture 
and inoculation has not yet fully been worked out. 

Bacillus of Malignant CEdema. — This organism was first de- 
scribed by Pasteur as the vib?'io?i septiqne, under which name it is 
to be found in French works on bacteriology. Its present name 
was given it by Koch, and it is an organism found in one of the 
laboratory diseases of animals. It is occasionally also found in the 
traumatic gangrene of man, and therefore deserves a place here. 
It has often been mistaken for the anthrax bacillus, but from 



68 SURGICAL PATHOLOGY AND THERAPEUTICS. 

which it is now readily distinguished. It is evidently a saprophytic 
organism, and is found in decomposing substances, in dirty water, 
and in dust, but is chiefly found in rich garden-mould. If such 
soil is injected into a guinea-pig, the animal dies in twenty-four or 
forty-eight hours, the oedema bacilli being found as the cause of 
death. They are slender rods, considerably narrower than anthrax 
bacilli, and are frequently seen together in bands which are often 
bent and curved. The bacilli have an active motion, but this 
motion soon ceases when the organism comes in contact with 
oxygen. Spores are formed in a temperature of above 20 C. 
They are large and are situated at the centre or the end of the rod 
(Fig. 19), which appears slightly distended at this point. The 



i/ 



\ 






\ 

I 

' 

- f 1 

® 9 \ 



1 



Fig. 19. — Bacillus of Malignant CEdema : cover-glass preparations from the liver of 

a mouse. 

bacilli are strictly anaerobic, and are sensitive even to the slightest 
traces of oxygen. They take well the aniline staining-fluids, 
and when colored the pointed ends of the rods distinguish them 
from the anthrax bacilli. They do not stain well by the Gram 
method. 

They grow best in gelatin cultures to which has been added 
from 1 per cent, to 2 per cent, of grape-sugar. In the early stages 
they form varicose prolongations at the lower portion of the needle 
track, and on the periphery form radiating fibres. Later the gela- 
tin melts gradually into a cloudy, opaque mass. There is usually 
a gas-formation which distends the needle track nearly to the sur- 



SURGICAL BACTERIA. 69 

face. The gas has a disagreeable odor, but it does not have the 
peculiar foul smell evolved by the genuine bacilli of putrefaction. 

If a pure culture of the cedenia bacillus is subcutaneously inject- 
ed into a guinea-pig, there is obtained an extensive bloody, ©ede- 
matous exudation of the muscular layer, but no pus nor foul odor 
and very slight gas-formation. The changes in the internal organs, 
liver and spleen, are very trivial. If, however, garden-soil is sub- 
stituted for the pure culture, there is then obtained an infiltration 
of the same tissues, with a dirty reddish serum which has a foul 
odor, and which may be purulent and be accompanied with an 
abundant gas-formation — in short, the picture of a progressive gan- 
grenous emphysema such as is often seen in traumatic gangrene in 
man. In this case there are found, in addition to the bacilli of 
oedema, other forms, such as the "pseudo-oedema bacilli," etc. A 
case of this kind is reported by Rosenbach — a compound fracture 
of the thigh and leg with subsequent gangrene. The thigh was 
amputated in the upper third. From the foul decomposing tissues 
of the limb a culture was taken immediately after the operation, 
from which culture he obtained a "saprogenic bacillus." 

The internal organs are but slightlv affected. If an animal be 
examined immediately after death, the oedema bacilli will be found 
in the superficial tissues of the body, but never in the blood-vessels. 
This arrangement is in striking contrast to that of the anthrax 
bacilli. But after death they rapidly spread throughout the body, 
and an active spore-formation occurs which does not take place 
during life. In the mouse inoculated with the bacilli of malignant 
oedema the course of events is somewhat different from that ob- 
served in the rabbit and guinea-pig : a rapid invasion of the entire 
body takes place during life, and the condition might easily be 
mistaken under these circumstances for anthrax. According to 
Chauveau, an animal which had recovered from malignant oedema 
was ever after insusceptible to this disease. Roux and Chamber- 
lain report that they obtained from the culture of these bacilli 
soluble substances which, when injected into animals, protected 
them from the action of the bacilli themselves. The ptomaine 
was obtained either by destroying the organisms with heat or by 
removing them with a filter, or the cedematous fluid from an inoc- 
ulated animal w T as used. An immunity was thus obtained. 

The ^pseudo-oedema" bacillus is described by Fliigge and Li- 
borius, who found it a frequent companion of the oedema bacillus. 
The pseudo-oedema bacillus is a somewhat thicker rod than the 
bacillus of malignant oedema, and possesses a very bright border. 



70 SURGICAL PATHOLOGY AND THERAPEUTICS. 

It is distinguished also by the formation of two spores in each rod. 
The bacilli are strictly anaerobic. In sugar-gelatin they are ac- 
companied in their growth by an abundant gas-formation, which 
has an odor of old cheese. Small doses of the culture are not 
infectious ; in large doses it kills mice and rabbits. Bordoni and 
Uffreduzzi in 1889 obtained from the cadaver of a man who had 
died of a disease similar to anthrax an organism closely resembling 
the pseudo-cedema bacillus, to which organism they gave the name 
i(, proteus hominis." Tricomi, an Italian observer, found a slender, 
long bacillus in the blood of patients suffering from senile gan- 
grene, and also around the line of demarcation and in the adjacent 
healthy tissues. He cultivated the organism on the various media, 
stained it with the aniline dyes, and succeeded in producing gan- 
grene in animals at the point of inoculation of the pure culture. 

Godwin obtained from a case of gangrenous emphysema cul- 
tures of streptococcus and the albus. W. Koch obtained from 
a case of progressive gangrene in a young man a bacillus closely 
resembling the bacillus of glanders. Bonnome found the pyo- 
genic cocci in a case of gangrene of the lung in man, and by 
mixing the cultures with fragments of pith, as has been shown 
elsewhere (p. 145), he enabled the cocci to be caught in the lungs 
of animals inoculated, thus reproducing the gangrene of the lung. 
Ivingard found long bacilli in noma, and similar organisms in gan- 
grenous stomatitis of cattle. Ranke found in cases of noma 
streptococci similar to those found by Koch in his experiments 
on field-mice. 

As Senn justly remarks, there is no specific organism to blame 
for traumatic gangrene, which may be caused, he thinks, either by 
the mechanical obstruction of the vessels by large numbers of organ- 
isms in the capillaries, or by the chemical action of the ptomaines 
on the tissues, or, finally, by the excess of exudation in a part 
which mechanically obstructs the return of the venous blood. 

Those appalling forms of traumatic gangrene, which are de- 
scribed elsewhere, are in many cases probably caused by the 
bacilli of the class to which belong the oedema and pseudo-cedema 
bacillus, which, with the pyogenic cocci, are always present, and 
are ready to attack wounds occurring in foul parts of the body or 
in tissues whose vitality has been destroyed by some injury. 

Bacillus Anthracis. — This organism deserves a place among 
surgical bacteria, not only because it produces the malignant 
pustule in man, but also on account of its historical position 
among bacterial diseases. It was not only the first of bacteria 



SURGICAL BACTERIA. 7 1 

found in diseased blood and tissues, but the investigation which 
demonstrated it as the true and only cause of splenic fever formed 
also the foundation upon which the science has subsequently been 
built up. 

In 1850, Davaine and Rayer announced to the Academie des 
Sciences that in animals affected with anthrax there existed in the 
blood little filiform bodies about double the diameter of a red 
corpuscle in length. These bodies did not possess spontaneous 
movements. After the subject had begun to attract the attention 
of the scientific world it was more carefully studied by Davaine 
himself, and later by Pasteur. But it was due to Koch that the 
existence of spores was discovered, and that cultures of the bacilli 
could be made and injected into animals, thus reproducing the 
disease. 

The bacilli, when grown on culture-media, are seen under the 
microscope as bright, transparent rods with slightly rounded 
ends. They are from 1 to 

1.5/z in thickness and from ' , Z 1 ^— <- 

3 to 6u long, and are en- % / "^^- J- X "\. . \ 

tirely without the power of ,* _ 

motion. If such bacilli are ~~ , [ \ 

placed in bouillon and ex- / 1 ^ / ~~~"~ .^ \ 

amined under the micro- C_ " y ' JS^ x ' 

scope, it is possible to ob- ®//S _^ / / 

serve the process of divis- | ^ 

ion, which takes place ~ /"\ N 



*i 



/ 



rapidly under somewhat 

high temperatures. The _Jt / V 

short rod-like cells grow ^\ — \ 

to long staffs which stretch / -' / ' ^-' j f ''/* 

across the field of vision, ~" 3& "^ 

and which show only here „ „ .„ A A 

J tig. 20. — Bacillus Antnracis; cover-glass prepa- 

and there indications of rations f rom the i iver Q f a mouse. 

being made up out of sev- 
eral cells. They now become somewhat less transparent, and, 
growing to great length, the chain of bacilli becomes twisted up 
into characteristic coils or knots (Fig. 20). 

If, however, the bacteria are taken from the blood of an animal 
dead of anthrax, and are colored in the usual manner, there is no 
longer seen the rounded ends just alluded to. They now appear 
somewhat larger at each end than in the centre, and articulate, as 
it were, with the other rods of the chain, like the phalangeal bones 



72 SURGICAL PATHOLOGY AND THERAPEUTICS. 

or the joints of a bamboo rod. This appearance is best shown 
with Bismarck-brown or methyl-bine. These organisms, when in 
the tissues, can be demonstrated by Gram's method, but they have 
an altered and granular appearance. The articulating enlarged 
ends of the bacilli are peculiar to anthrax, and distinguish these 
bacteria from all other forms. In using Gram's method care 
must be taken not to bleach too much, as the bacilli readily give 
up their color. 

If it is desired to see the spores, the bacilli must be examined 
in a drop of bouillon. Having reached the stage of development 
already described, the bacilli begin to show in the middle of the 
rod little accumulations of thickened protoplasm, that unite to 
form a large glistening body which appears as a bright spot of 
irregular outline in the middle of the cell. This body increases in 
size and brightness, is surrounded by a well-defined membrane, 
and is about the same width but somewhat shorter than the 
bacillus. It is sometimes wider than the cell, and when many of 
these bright egg-shaped bodies have formed in a chain of bacilli, a 
striking picture somewhat like a string of pearls is obtained. 
Presently the transparent remnant of the protoplasm, which has 
not been used for the formation of the spore, is dissolved and the 
spore is liberated. 

If the spores are now placed in fresh bouillon, they begin to 
germinate. This process can be watched in a hanging drop of 
liquid agar, which soon hardens and holds the spore, so that they 
can be observed during the different stages of their development. 
The spore soon loses its glistening appearance and increases in 
length. The tough membrane is next ruptured at one end, and 
the young bacillus projects from the opening. It continues grow- 
ing in the direction of the long axis of the spore, and finally casts 
off the shell of the spore and appears as a completely-developed 
bacillus. The growth of the bacilli is most active at a tempera- 
ture of 37 C, the extreme range of temperature being from i6° 
C. to 45 C. Access of oxygen is necessary. The spores do not 
germinate at a temperature below 24 C, and they need a large 
supply of oxygen. Spores do not form, therefore, either in the 
living body or in the cadaver of an animal which has died of the 
disease. They grow best artificially on the surface of agar or of 
potato, or in thin layers of bouillon, or in human urine freely 
exposed to the air. 

The bacilli have comparatively a slight resisting power : they 
are readily destroyed at a temperature of 6o° C. , and are unable to 



SURGICAL BACTERIA. 73 

live more than a few weeks in the dry state. The spores, however, 
belong to the most durable of bacterial organisms. It is difficult 
to destroy them with chemical agents, and when they exist in a 
state of nature sunlight alone appears to have a destructive action 
upon them. These spores are used as a standard test of the value 
of disinfectants, and threads dried in spore-cultures may be pre- 
served for an indefinite length of time and used for this purpose. 
In gelatin the track of the needle is found filled with a whitish 
growth, from which delicate white threads project into the sur- 
rounding medium. On the surface the gelatin begins to liquefy, 
and at the bottom of the fluid is seen a slimy white layer of bacteria 
which gradually settles deeper as the liquefaction proceeds. On 
the surface of obliquely-hardened agar the bacteria appear as a 

; "■'"■:" ' ; 






\\ 



v \ 






1 /> 






x^7 



/> 



b 



Fig. 21. — Section of Kidney from an Animal dead of Anthrax, showing bacilli in blood- 
vessels. 

grayish-white growth with a dull silver hue and raised somewhat 
above the surface. 

The virus may be introduced into the system in various ways. 
It may be inoculated even in very small quantities, and will pro- 
duce a fatal septicaemia, as it is reckoned among the most highly 
infectious of the bacteria. Buchner succeeded in introducing the 
spores and also the bacilli into the respiratory passages by inhala- 
tion. The bacilli produced much more irritation than the spores, 



74 SURGICAL PATHOLOGY AND THERAPEUTICS. 

and pneumonia occurred. Baumgarten is doubtful whether this 
mode of infection occurs outside the laboratory. When taken into 
the stomach with food the bacilli are usually destroyed by the 
gastric juice, but the spores reach the intestinal canal. The alka- 
line character of the secretions and the high temperature give them 
an opportunity to germinate. They attach themselves to the 
epithelium and develop rapidly on the surface : the cells are then 
pushed aside and the bacilli reach the deeper layers of the mem- 
brane. Sheep and oxen are particularly sensitive to this form of 
infection, it being the one which under natural conditions plays 
the most important role. In man the infection most frequently 
takes place through wounds, and it forms the malignant pustule, 
but it has also been observed to gain an entrance through the 
lungs, giving rise to a pneumonia. 

One of Pasteur's most brilliant scientific feats was the demon- 
stration of the possibility of protecting an animal from the virus 
of anthrax by vaccination. It was found that cultures of the 
bacilli, carried on at high temperatures, were weakened in their 
poisonous action. The same result could be obtained by growing 
them at a moderately high temperature for a considerable length 
of time. Organisms treated in this way were found to produce 
alkaline substances, whereas the bacilli of natural strength produced 
acid substances. It was thought that this discovery would prove 
of great practical value, but experience has shown that, although 
sheep are protected by the vaccine thus produced from an inocula- 
tion with bacilli of full strength, the immunity is not permanent, 
but lasts only about a year, and, moreover, that it does not protect 
against infection through the intestinal canal. As this is the most 
frequent form of infection in cattle, further experiments are neces- 
sary to determine whether it is possible to devise a practical system 
of vaccination of cattle. 

An albuminose has been been separated from anthrax cultures 
in Koch's laboratory by precipitation with absolute alcohol. It 
was then redissolved and filtered through a Chamberland filter. 
Injected into animals, it was found to exert a protecting influence. 

According to Pasteur, the strength of the anthrax virus may be 
restored by inoculation into susceptible animals. Cultures from 
the blood of such animals will have an increased virulence. 
Cenkowski in Russia succeeded in obtaining an improved vaccine 
by passing the virus through the marmot {Zieselmaus) until a 
definite strength was obtained. The cultures of this vaccine were 
preserved in glycerin. L,ess than i per cent, of the animals were 



SURGICAL BACTERIA. 75 

killed by the vaccine, and his tables show that during four years 
of its use, a larger number of animals being vaccinated each year, 
there was a diminution of the anthrax mortality in the herds from 
8.5 and 10.6 per cent, to 0.13 per cent. An examination of the 
infected tissue shows the bacilli chiefly in the capillary system ; few 
organisms are seen in the large vessels, whereas the capillaries are 
crowded. They are found in the spleen, in the liver, and in the 
kidneys (Fig. 21), particularly the glomeruli. In the capillaries of 
the intestinal mucous membrane is occasionally found a ruptured 
vessel through which the organisms have escaped into the sur- 
rounding tissue. 

It was thought at one time that bacilli were eliminated with the 
various excretions, but it has been maintained that it was impos- 
sible for the bacilli to pass through the walls of the capillaries. 
Baumgarten is, however, of the opinion that the bacilli are as well 
able to migrate as are the leucocytes. Inasmuch as the capillaries 
of the kidneys are filled with these organisms, it is not surprising 
that the bacilli are found in the urine. It is also quite certain that 
they can pass through the placenta and affect the foetus, whether 
by penetrating through the walls of the blood-vessels or by escap- 
ing into the extravasations which are so numerous in the placenta. 

Rosenblath inoculated five pregnant guinea-pigs with anthrax. From the 
nine foetuses he obtained anthrax cultures in five. As the infection of the 
foetus does not always take place, it is probable that the bacilli pass through 
the placenta only under unusual conditions. The very frequent hemorrhages 
which accompany the disease probably give the bacilli an opportunity to 
escape from the circulation of the mother into that of the foetus. 

The bacilli are supposed to exert their pathological action in 
several ways: First, by so crowding the capillaries as to interfere 
with the nutrition of the parts; secondly, by robbing the tissues of 
oxygen; and, finally, by the formation of a toxine which exerts a 
poisonous influence. 

As the spores are the organisms which have preserved this 
disease from time immemorial, and which make it so difficult, 
even with our present knowledge, to prevent epidemics, it is 
interesting to consider how cattle are exposed to their influ- 
ence. During an epidemic the discharges from the intestine, the 
bladder, and the nostrils are scattered about on the surface of 
the earth in the track of grazing cattle. The organisms find a 
resting-place also in their hides. It was at one time thought that 
the bodies of buried animals might be a source of infection, but 
the conditions for germination at some depth beneath the surface 



76 SURGICAL PATHOLOGY AND THERAPEUTICS. 

of the ground are not found to be favorable. The spores, there- 
fore, find a resting-place only in the superficial soil. They may 
be freed from their surroundings either by wind or by flood, and, 
mingled with the food of animals, may become the source of a 
fresh epidemic. Man is exposed to infection chiefly from contact 
with diseased animals or from handling their hides or wool; hence 
the name "wool-sorter's disease" has been given to anthrax in 
man. 

Actinomyces is a form of fungus which was first described by 
Bollinger in 1877 as existing in cattle, and which Israel found also 
in man a year later. It did not become generally understood, 
however, until Ponfick's article appeared in 1882. Bollinger 
found it in peculiar lumps about the jaws, the throat, or the 
tongue of animals, which lumps were supposed to be tubercle, 
cancer, and various other affections. In man the fungus is 
accompanied more or less by extensive suppuration in the same 
localities and also in other parts of the body. The organisms 
seen by the naked eye appear as a growth about the size of a 
millet-seed: they are yellowish, sulphur-like bodies of a tallowy 
consistence, which bodies, seen under the microscope, consist of a 
cluster of straight or of wavy branching threads, and also of 
radiating prolongations quite thick and clubbed- or pear-shaped, 
appearing sometimes like the fingers of a hand. These prolonga- 
tions are so arranged as to give the growth the appearance of a 
sunflower. The size of these colonies varies greatly, ranging from 
scarcely visible bodies to nodules 2 mm. in diameter. Their color 
may also vary from the light yellow mentioned to whitish, light 
brown, or green, and their surfaces may be smooth or mulberry- 
shaped. The club-shaped ends may be wanting, and the growth 
then appears very much like the streptothrix found as concretions 
in the lachrymal ducts of man. The radiating arrangement of the 
threads may also be wanting, in which case the growth is not 
unlike the leptothrix found in the mouth. It has been thought by 
some that these different appearances indicate a mixed growth of 
organisms, but culture-experiments prove that this is not the case 
— that the organism belongs to a polymorphous or cladothrix 
variety of fungus. 

The organism is colored with difficulty. The finer threads take 
the aniline colors well, but the club-shaped prolongations do not 
take the staining. They appear to be the result of a retrograde 
change in the growth. A portion of a nodule is spread upon a 
cover-glass and is allowed to dry. The glass is then heated in the 



SURGICAL BACTERIA. 77 

flame of a lamp, and a few drops of picrocarmine solution are 
allowed to fall upon it. After two or three minutes the prepara- 
tion is washed in distilled water and alcohol and examined in 
water and glycerin. The fungus takes the yellow staining, while 
the other structures appear red. When sections are examined 
Gram's method of staining may be used. The actinomyces 
colonies are then seen stained a bright blue, surrounded by a zone 
of the clubbed ends colored a pale yellowish-pink; around this a 
zone of pus and of granulation-tissue colored pink; and, outside 
of all, the several tissues stained red. Sections may also be 
stained in Ziehl's carbolic fuchsin for fifteen minutes to half an 
hour, and then decolorized in a i per cent, picric-acid solution 
until the whole section has a yellow appearance. Dehydrate and 



mu. 







^P 



# 



Fig. 22. — Section of Tumor of a Calf, showing actinomyces. 

mount. The fungus appears as a brilliant red aster, while the 
surrounding tissues are colored yellow (Fig. 22). 

According to Baumgarten, it is difficult to get a pure culture 
unless the growth be stirred in liquid gelatin, which is then 
poured upon a glass to harden. It can thus be grown upon blood- 
serum, gelatin, or agar. The cultures develop best at tempera- 
tures of from 33 to 37 C, and the growth is complete at the end 
of five or six days. When grown on the surface the line of inocu- 



78 SURGICAL PATHOLOGY AND THERAPEUTICS. 

lation widens and has a granular whitish appearance. Presently 
small, yellowish-red nodules form in the centre of the culture, 
while the border is surrounded by a delicate white fringe. 
Finally, the nodules run together and are covered by a white 
velvety coat. 



III. HYPEREMIA. 

Among the most elementary disturbances in the whole domain 
of surgical pathology, in many cases so slight as hardly to be 
called kW pathological," are those changes in the circulation known 
as hypercrmia. From the earliest times these vascular disturbances 
have been recognized as the effect of some form of irritation act- 
ing upon the organism, as is evident from the phrase " ubi stimulus 
ibi affluxMs" handed down by early writers. It was not, however, 
until Claude Bernard gave the impetus to special research in this 
direction by his discovery in 1851 of the result of section of the 
cervical sympathetic nerve that any extended scientific study of 
the condition was attempted. Since then the science of angio- 
neurology, "one of the most important doctrines in medicine," 
has been evolved. The importance of a study of this subject need 
hardly therefore be urged as essential to a proper understanding of 
some of the more complicated pathological problems which will 
engage the reader's attention later. 

Hyperaemia signifies an increased amount of blood in a part. 
When, on the one hand, there is an increased amount of blood in 
all the vessels of the body, the condition known as plethora exists. 
On the other hand, anaemia is a term used to denote the condition 
existing when there is less blood than usual in the body. This 
term is, however, used in a medical sense to indicate certain 
pathological changes in the blood. Finally, ischaemia means a 
decreased flow of blood to a part. 

Hyperaemia is of two kinds — active and passive. In active 
hyperaemia there is an increased flow of arterial blood to the part. 
This condition has sometimes been called "fluxion." In passive 
hyperaemia there is a slowing of the blood-current ; the blood is 
venous in color ; a condition of stagnation exists. The condition 
of the circulation in active hyperaemia is well described in the 
account of an experiment by Vulpian on the vaso-motor effects 
produced by faradic stimulation of the peripheral segment of the 
lingual nerve in a dog. There is a considerable dilatation of all 
the vessels of the corresponding half of the tongue in the region in 
which this nerve is distributed. The mucous membrane in this 

79 



So SURGICAL PATHOLOGY AND THERAPEUTICS. 

region and also on the corresponding side of the frsenum becomes 
bright red. The principal vein of this part of the tongue becomes 
turgescent, and the blood contained in it and its tributaries is 
bright in color, resembling that of arterial blood, while there is a 
corresponding rise in the temperature of the part. 

In active hyperaemia there is an increased rapidity of flow of 
the blood, not only through the arteries, but through the veins also. 
If an artificial hyperaemia be produced in a dog's paw by division 
of the sciatic nerve, there will be found an increased tension in the 
femoral vein, as shown by a canula inserted into that vessel and 
placed in connection with a manometer. If the vein be tied, there 
is an almost arterial pulsation in it. There is, then, in hyperaemia 
an increased pulsation and dilatation of the arteries and a filling of 
the veins with arterial blood. Even the smallest arterioles, which 
do not pulsate ordinarily, begin to pulsate as soon as pressure is 
made upon them. The condition of the capillary vessels can con- 
veniently be studied in the web or the tongue of a frog. Under 
normal conditions the capillaries contain but few corpuscles, one 
or two at a time flowing through, and apparently filling out, the 
lumen of the vessel ; at times only liquor sanguinis is observed. 
Under a slight stimulus there is marked increase in the rapidity of 
the flow of the corpuscles, and the little vessels are distended with 
them, many appearing in the field of the microscope that were 
not before observed. Both the arteries and the veins are much 
dilated, and the rapidity of the flow is greatly increased. Whether 
there is or is not an actual dilatation of the capillaries is still a 
disputed question, as the absence of muscular and elastic walls in 
the capillaries does not permit of the marked changes of calibre 
seen in other kinds of vessels. Strieker, however, has an explana- 
tion which enables him to assume that active dilatation and con- 
traction of the capillaries take place. Experiments on the glan- 
dular vesicles of the skin of a frog, representing a single acinus 
and duct, show that under the stimulus of the faradic current the 
cells which line the acinus swell up and diminish the calibre of the 
acinus, and that on removal of the stimulus the same cells shrink 
and enlarge the cavity. A similar swelling of the cells forming 
the capillary walls has been observed, and the changes in the size 
of the lumen of these little vessels are supposed by Strieker to 
occur in this way. 

The following, then, are the principal changes seen in active 
hyperaemia. There is a temporary increase in the amount and 
rapidity of the flow of blood, and when this has subsided the circu- 



HYPEREMIA, 81 

lation goes on as before, and no perceptible change in the part 
appears to take place. Ordinarily, there is no escape of fluid from 
the walls of the vessels, and if a canula is placed in a lymphatic 
of the leg of a hypersemic animal, no increased flow of lymph 
will be found. CEdema may, however, sometimes occur to a 
moderate extent, and the wheals of urticaria are supposed to be 
examples of such a condition. Occasionally there may even be 
rupture of the vessels and hemorrhage, but this only occurs when 
there is some pathological complication or when the vessels them- 
selves are diseased. Usually the effect of hyperemia is quite the 
opposite ; the walls of the vessels, instead of becoming thinner, 
are actually thicker, having undergone hypertrophy from the 
hypersemia, probably of the vasa vasorum. 

The increased warmth accompanying hyperemia is easily 
explained. The temperature of the surface of the body is always 
less than that of the interior, as considerable elimination of heat 
is constantly taking place. Indeed, the variations of temperature 
on the surface may be considerable. If now an increased amount 
of warm blood from the interior of the body flows through a given 
territory, the tissues become warmer and the temperature of the 
part is raised. Increased nutrition of the part, or increased activity 
of the muscular walls of the vessels considered as sources of heat, 
can hardly be sufficient to produce any perceptible local increase 
of temperature. 

The apparatus by means of which these vascular changes are 
accomplished is known as the vaso-motor system. The origin of 
the vaso-motor nerves or the vaso-motor centres has been traced to 
the medulla oblongata. The exact spot has variously been stated 
as at the boundary-line of the cervical and dorsal portions of the 
cord, or in the anterior portions of the lateral columns, or in the 
lower part of the floor of the fourth ventricle near the point of the 
calamus. 

These nerves can be divided into two groups. A large majority 
leave the spinal nerves with the rami communicantes, enter the 
sympathetic, run upward or downward, and terminate in independ- 
ent branches of the sympathetic or the splanchnic nerves which 
supply the abdominal organs; or, after entering the sympathetic, 
they return through the rami communicantes to the spinal nerves, 
and are distributed with them to the skin, muscles, and bone. 
Another group does not enter the sympathetic at all, but takes its 
course in the spinal nerves. The latter groups are called the 
u direct supply, " and the former the "indirect supply," of vaso- 

6 



82 SURGICAL PATHOLOGY AND THERAPEUTICS. 

motor nerves. The sympathetic does not form a separate system, 
but is connected with the spinal nerves. The cervical portion 
receives fibres from the first dorsal nerve-roots. The nerves which 
enter the sympathetic for the lower extremities come from the 
lumbar nerve-roots. 

The classical experiments of Claude Bernard gave the first 
information as to the physiological action of the vaso-motor 
system. The division of the cervical sympathetic in the rabbit 
was shown by him to be followed by marked hypersemia or dilata- 
tion of the blood-vessels in the ear. This was finally explained 
by supposing a paralysis of the vaso-constrictor nerves to have 
taken place. The same observer, however, discovered that stimu- 
lation of the chorda-tympani nerve produced dilatation of the 
vessels in the submaxillary gland. Here, then, was a demonstra- 
tion of two different kinds of nerves in the vaso-motor system, one 
of which by its action constricted the blood-vessels; the other, 
when in activity, produced a dilatation of the vessels. For a long 
time the chorda tympani and the nervi erigentes of the corpora 
cavernosa were supposed to be the only examples of the dilator 
nerves. Goltz, however, undertook to demonstrate the presence of 
the vaso-dilator fibres in the sciatic nerve of animals. He found 
that section of this nerve was followed by dilatation of the blood- 
vessels of the limb, which after a while resumed their natural 
calibre. Cutting off a second fragment from the peripheral portion 
of the nerve reproduced the dilatation. These phenomena were 
explained by the presence of vaso-dilator nerves which were 
irritated by the section. Other observers, however, showed that 
if the peripheral end of the divided sciatic was stimulated there 
took place a contraction of the vessels, which later gave way to 
dilatation due to exhaustion ; the nerves therefore were constrictors, 
and not dilators. 

Ostroumoff found, however, that in curarized dogs the freshly- 
divided nerve contracted when irritated, but that three or four days 
later the same irritation produced dilatation; time, therefore, was 
an element of importance in the problem. He assumed that 
both kinds of nerves are present, and that the vaso-constrictors 
degenerate soon after section, but that the dilators degenerate 
slowly. 

It has been noticed by all observers that the dilatation following 
section of the sciatic subsides at the end of a few days. This 
change is said to be brought about by the perivascular ganglia, 
which, with the nerve-plexus uniting them, are supposed to acquire 



HYPEREMIA. 83 

gradually a higher degree of activity after separation from the 
nerve-centres. 

Such a system of ganglia and nerves has never been demonstrated 
anatomically ; no one has ever seen it, but there is found in the 
walls of the small intestine a similar plexus of nerve-cells and 
nerve-fibres, which plexus seems to preside over the movements of 
that organ, and to be subjected to excitation and inhibition through 
nerve-fibres connecting them with the cerebro-spinal centres. 
Microscopical clusters of ganglia have been seen on the arteries 
of the submaxillary gland, as also in the neighborhood of the large 
vessels of the penis. 

Strieker explains the phenomena supposed to be caused by the 
local ganglia in another way : he assumes that recovery from 
hyperaemia following section of the cord is accomplished by nerve- 
branches which are given off from the cord above the point divided, 
and which anastomose with the nerves going to that part. These 
nerve-branches gradually acquire increased power, and eventually 
exert a sufficiently powerful action upon the dilated vessels to cause 
them to contract again. This he calls " collateral innervation." 

In the light of the investigations which have been quoted we 
are justified in assuming the existence of the vaso-constrictor 
nerves and the vaso-dilators, which place the blood-vessels in com- 
munication with the vaso-motor centres. A peripheral vaso-motor 
mechanism also exists, presided over by the so-called "perivascular 
ganglia." The perivascular ganglia and the vaso-constrictors are 
continuous in action ; they keep the muscular walls of the blood- 
vessels in a state of tonic contraction, or, in other words, they give 
them their proper tonus. 

The dilators are not always in action, but are called into play 
only under exceptional circumstances. According to some author- 
ities, these nerves act like the vagus by producing an inhibitory 
action upon the local ganglia. Others believe them to have the 
ability to dilate the blood-vessels directly by their own action. 
Among the latter authorities is Strieker, who has shown that the 
dilators emerge from the cord through the posterior or sensitive 
roots. Most physiological and many pathological hypersemias are, 
according to him, produced by an irritation of the dilators. The 
close anatomical relationship between the sensitive and dilator 
nerves would explain the existence of hyperaemia in connection 
with many forms of neuralgia and the presence of pain accompany- 
ing the congestion of inflammation. He says: "It is probable 
that the local irritation excites at the same time both the sensory 



84 SURGICAL PATHOLOGY AND THERAPEUTICS. 

nerves and the vaso-dilators of the implicated region. Whilst the 
former cause pain by centripetal conduction, the latter produce a 
dilatation of the vessels by centrifugal conduction." 

There may be found however, a vascular hyperaemia produced 
by purely reflex action. Goltz irritated the central end of a divided 
sciatic nerve, and obtained sometimes a dilatation and sometimes a 
contraction of the vessels in the opposite leg. Brown-Sequard and 
Lombard, after irritation by pricking, found a rise of temperature 
of a man's skin on the same side of the body, and a fall of tem- 
perature on the other side. These changes, though slight, were 
observed by Lombard's very delicate thermo-electric apparatus, 
and they indicated contraction or dilatation of the vessels. Numer- 
ous examples of this form of hyperaemia may be given. Neuralgic 
affection of the knee-joint with swelling is observed to be dependent 
upon uterine disorder. The danger of sympathetic inflammation 
of the sound eye following injury to either one of the eyes is well 
recognized. Weir Mitchell has observed a burning in the sym- 
metrical part following injury to a certain portion of the body. A 
lowering of temperature has also been observed in one hand on 
placing the other hand in cold water. The application of ice-bags to 
the heart, the abdomen, and the thighs has produced contraction of 
the blood-vessels in distant portions of the body. In fact, a system of 
treatment has been based upon the sensitiveness of the vaso-motors 
to heat and cold. It is a well-recognized fact that headache may be 
relieved, that nose-bleed may be stopped, and that the catamenial 
flow may be established by judicious use of these remedies, and it 
is not surprising that still greater claims are made for these 
remedial powers when there is taken into consideration the very 
considerable disturbances in the distribution of blood to different 
parts of the body, which disturbances may be produced experi- 
mentally. Irritation of the splanchnic nerves, on the one hand, 
produces contraction of the powerful abdominal blood-vessels 
and increases greatly the arterial tension throughout the body; on 
the other hand, division of the splanchnics produces hyperaemia 
of these vessels. Strieker says: "If this reservoir is wide open, 
it can contain so large a portion of the total amount of blood that 
the rest of the body becomes anaemic. An animal with complete 
paralysis of the abdominal viscera therefore bleeds to death, as it 
were, into its own abdominal vessels." In this condition there 
is dilatation of the mesenteric and of the renal arteries. At the 
same time on division of the portal veins an increased flow of 
blood is observed. No increase of temperature was found in the 



HYPEREMIA. 85 

abdominal organs after division or irritation of the various nerves 
and ganglia supplying them, as they already possessed the highest 
temperature of all parts of the body. Such is the condition of the 
abdominal vessels in the frog in the well-known Goltz experiment. 
This experiment consists in tapping the abdomen of a frog with 
light but frequent blows, which result in a temporary cessation 
of respiration, heart-pnlsation, and muscular action, from which 
condition, however, the animal speedily recovers. As all local 
hyperemias are accompanied by compensatory local anaemias 
somewhere else to preserve the pressure, it can easily be seen that 
the blood-vessels of the abdominal viscera can become the regula- 
tors of the blood-pressure throughout the body. 

As hyperemia may be caused by paralysis of the constrictors or 
by irritation of the dilators, two forms of active hyperemia must 
be recognized. When caused by a paralysis of the constrictors it 
is known as hyperemia of paralysis, or neuro-paralytic conges- 
tion; when caused by an irritation of the dilators it is known as 
hyperemia of irritation, or neuro-tonic congestion (Reckling- 
hausen). The various elements which combine to form the vaso- 
motor system tend to counteract one another, and, in disturbances, 
to restore the normal condition. If a sudden change takes place 
in one direction, a reaction in the opposite direction may soon 
occur. After long exposure to cold there is a tendency to conges- 
tion of the part; to avoid this, frozen parts must be warmed slowly; 
conversely, the arm and hand which have been held for a long 
time in warm water may become paler than usual. 

One of the most striking examples of hyperemia of paral- 
ysis is observed after gunshot injury of the cervical sympathetic. 
A case is reported by Mitchell, Morehouse, and Keen that at 
the end of six weeks showed unilateral hyperemia of the face 
after an unusual exertion, with redness of the conjunctiva, con- 
traction of the pupil, secretion of tears, and ptosis. A similar 
injury recently occurred during the writer's service at the hospital, 
that was followed immediately by changes in the pupil and hyper- 
idrosis of the injured half of the face and the neck. Hutchinson 
observed, after fracture of the clavicle, paralysis of the arm, 
narrowing of the pupil, and rise of temperature of the injured 
half of the face. Such evidences of pressure on the cervical sym- 
pathetic in this injury he considers not unusual. A more exten- 
sive form of this kind of paralysis is given by Groningen. A 
laborer lying on his back after a full meal was playfully hit upon 
the stomach with a plank; in fifteen minutes he was dead, and at 



86 SURGICAL PATHOLOGY AND THERAPEUTICS. 

the autopsy no structural lesion could be found in any part of the 
body. Many examples of syncope due to blows upon the chest and 
the abdomen, followed by death or recovery, and usually ascribed 
to shock, are undoubtedly caused by a reflex paralysis of the heart 
and the abdominal vessels. As the treatment of these cases is 
very different from that adapted to shock, it is important that the 
two conditions should be distinguished from each other. The 
action of the heart in cases of vaso-motor paralysis can be restored 
by electric stimulation or frictions and by compression of the 
abdominal walls to force the blood forward into the heart, whereas 
in shock absolute' rest is of the utmost importance. 

But few examples of hyperemia of paralysis are recorded as 
following injuries of the nerves of the extremities. An observa- 
tion by Waller on the ulnar nerve is worth mentioning here: The 
nerve at the bend of the elbow was placed on a freezing mixture 
until all sensation was lost. A rise of temperature with conges- 
tion was then noticed in the skin between the third and fourth 
fingers, and in some cases this condition lasted several days. 
Swelling of the finger-joints has been noticed following fracture 
of the internal condyle of the humerus causing pressure on the 
ulnar nerve. The same condition sometimes follows Colles's 
fracture, and is probably produced by pressure upon the nerves of 
the wrist by the displaced upper fragment. 

The hyperemias of dilatation are, as a rule, shorter and quicker 
in their action. They are accompanied by nervous symptoms, 
such as neuralgic pain, active secretion of the gland supplied by 
the nerve, oedema, and desquamation of epithelium from mem- 
branes. The changes of color in the cheek following disturbance 
of the emotions, as shame or anger, are regarded as examples of 
this form. The flushing following the stimulating effects of 
alcohol, tea, and coffee is supposed to be due also to stimulation of 
the dilator nerves. Redness of the conjunctiva, and even of the 
forehead and cheek, with flow, of tears, is an occasional accom- 
paniment of facial neuralgias, and is a symptom in accord with 
observations of Strieker on the presence of the dilators in the 
sensory roots. In fact, in hemicrania a dilatation of the vessels 
of the retina, both arteries and veins, has been observed. Perhaps 
the most striking example of hyperemia following nerve-irritation 
is herpes zoster. Not only does the eruption follow the anatomical 
distribution of nerves, but evidences of inflammation have also 
been observed in the nerves themselves by Haight and others. 

Cases of erythema, described by Mitchell, Morehouse, and 



HYPEREMIA. 87 

Keen, following irritation of nerves previously severed by gunshot 
injury, are probably due to an active dilatation of the vessels. 
Redness and swelling of the joints have been observed by Weir 
Mitchell in cases following gunshot injury of the brachial plexus, 
and by Packard in a case of compression of the sciatic nerve by a 
tumor. The conditions described by Mitchell as erythromelalgia 
may be classed with these hyperaemias. The reflex hyperaemias 
are said by Recklinghausen to belong to this class also. 

Hyperaemia caused by paralysis of the perivascular ganglia 
may be observed in parts of the body separated from the nervous 
centres, as in transplanted flaps, where an unusual susceptibility 
to heat and cold is ordinarily shown by changes in the calibre of 
the vessels. A hand and forearm separated from the nervous 
centres by division of the nerves exhibited this increased suscept- 
ibility : on dipping the hand into cold water congestion with the 
formation of vesicles took place. A bright blush suffuses a limb 
after removal of an Esmarch bandage and the capillary hemorrhage 
from the wound is for a short time quite active if means have not 
been taken to prevent its occurrence. The dilatation of the blood- 
vessels is here evidently due to a local influence exerted directly 
upon them, either as the result of pressure or the removal for a 
certain length of time of the nutrient blood. Whether this local 
influence is exerted partly upon the muscular apparatus of the 
vessel-walls directly, and not through the perivascular ganglia, is an 
open question. The congestions of the walls of sacs following- 
evacuation of their contents belong to this class. Tapping the 
abdomen for ascites may be followed by heart failure or by serious 
hemorrhage into the peritoneal cavity if the pressure of the fluid is 
not replaced by external support. Too rapid evacuation of a 
bladder distended by obstruction from enlargement of the prostate 
may be followed by hsematuria and cystitis. In such a case the 
vessels of the bladder-wall are suddenly deprived of a support to 
which they have been accustomed for months or for years perhaps, 
and have lost the tonus which enabled them to preserve their 
normal calibre. This rapidly-produced hyperaemia is followed by 
rupture of some of the vessels or by a congestion terminating in 
inflammation. ' A portion only of the urine should be removed 
from such a bladder in order to allow the blood-vessels time to 
regain their tonus. A similar condition is often seen in limbs after 
fracture. The distention of the blood-vessels so characteristic 
during the first attempts to place the foot upon the ground after 
prolonged rest in the horizontal posture is in part due to increase 



88 SURGICAL PATHOLOGY AND THERAPEUTICS. 

of pressure from the vertical position. The relaxing effect of 
moderate heat upon the vessels of the hand on placing it in warm 
water is familiar to every one. Very hot water will stimulate the 
constrictors, and is therefore useful in arresting hemorrhage from a 
wound. Prolonged douches of hot water have a similar astringent 
effect, and are used upon the cervix uteri for this purpose. The 
class of remedies known as rubefacients have probably a local 
action only on the blood-vessels ; when very stimulating they will 
produce primary constriction followed by dilatation of the vessels. 
It is supposed that many of the erythematous eruptions seen in 
bacterial diseases," such as, for instance, surgical scarlet fever, are 
produced by the local action of the bacteria or their toxic products 
upon the vessels. The artificial congestion produced by cupping 
is not a pure example of either active or passive hyperemia, as the 
vacuum draws the blood from all quarters indiscriminately ; that 
is, partly from the arteries and partly from the veins. 

Hyperemia is, as a rule, a passing condition, and, as already 
stated, leaves the part in the condition it was before ; long-con- 
tinued hyperemia may lead to hypertrophy of the vessels, and also 
of the part itself, as hypertrophy of the heart from hyperemia of 
the coronary arteries. When dilatation of the blood-vessels comes 
on suddenly and is intense in character, there may be an exudation 
of plasma from the vessels and oedema will take place. This is 
particularly noticeable in soft tissues, as the eyelids, in the neigh- 
borhood of inflammations, and is known as collateral oedema. It 
is probable, however, that in these cases there is not a pure exam- 
ple of hypersemia, but that other elements are at work, of which 
more will be said when studying inflammation. CEdema, and even 
hemorrhage, may, however, occur as the result of pure hyperemia, 
as is seen in many forms of skin eruption. At times excessive 
glandular secretion occurs : this is observed in the mucous mem- 
branes and also in the skin. It is a question whether the secretion 
is the result of a reflex irritation of the nerves going to the gland- 
cells or of the dilatation of the blood-vessels of the gland. In 
very chronic cases there is found, in addition to hypertrophy, an 
unusual growth of hair on the part. 

Passive hyperemia is caused by partial or by complete obstruc- 
tion of the flow of blood through the veins. It can be produced 
artificially by placing a ligature around a large vein. If this vessel 
be placed in communication with a registering apparatus, it will 
be found that there will be considerable increase of pressure at 
first, but that in a short time the pressure has returned to normal. 



HYPEREMIA. 89 

The blood has found its way around the obstruction through the 
neighboring veins, which exist in abundance. If, however, a 
tourniquet is placed around a limb tightly enough to obstruct only 
the veins, but not the artery, there will soon be seen a rise in the 
pressure, which will become almost equal to that in the arteries. 
There may even be a pulsation in the veins. The same condition 
will be established after obstruction of a single vein in organs 
which have only one vein, as the kidney. Obstruction of the 
portal vein and of the femoral vein under Poupart's ligament will 
also be attended by such serious disturbance. 

In this form of hyperemia the color of the skin will be bluish 
or dark red. When the surface is unusually transparent, as under 
the nails, there is a livid or cyanotic hue. The change of color is 
most marked at the extremities, where the capillaries are large, or 
where the arterioles terminate in veins without an intermediate 
capillary system. The temperature of the surface is cooler than 
usual, this being due to the slowing of the blood-current, thus 
allowing less warm blood than usual to pass through the tissues. 
The venous color appears to be due in part also to this state of the 
current, for the blood remains longer in the part, and consequently 
becomes more highly charged with carbonic acid and more com- 
pletely deprived of its oxygen. In amputation wounds the 
venous color of the blood flowing from the surface is marked while 
compression is still partly exerted by the tourniquet, and the flow 
is more rapid than normal, owing to the increased pressure in the 
veins. Such hemorrhage will, however, speedily be arrested by 
removing the tourniquet and allowing the current to flow in its 
natural direction toward the heart. 

The minuter changes in passive hypersemia may be studied in 
the frog's tongue after tying the veins on either side. There is at 
first an appreciable slowing of the current in the small veins and 
in the capillaries. These vessels soon become filled and distended 
with blood-corpuscles, the plasma-layer in the smaller veins dis- 
appearing entirely. The red corpuscles now appear to lose their 
contour and become fused together in an almost homogeneous mass. 
The flow of blood ceases, and the blood-column has a rhythmical 
pulsation communicated to it with each heart-beat. Presently at 
isolated points red corpuscles appear projecting through the walls 
of the capillaries and small veins, and finally they are forced com- 
pletely through, owing to the pressure to which they have been 
subjected. There is at the same time also an escape from the 
vessels of a certain amount of fluid, which gives rise to oedema 



90 SURGICAL PATHOLOGY AND THERAPEUTICS. 

caused by the pressure exerted upon the small vessels both by the 
veins and the arteries. In the arteries no increased pressure is 
observed, as their tonus is always higher than any pressure that 
can be produced by this form of hyperaemia. 

A study of the arteries of the retina shows that they are 
narrower than usual under these circumstances. This contraction 
of the arterioles is supposed to be either compensatory, so as to 
bring less blood to the congested part, or is for the purpose of 
making the blood-stream more powerful. The exuded fluid is 
poorer in albumin than the liquor sanguinis or pure lymph; and it 
has but slight tendency to coagulate. The reddish tinge some- 
times given to the fluid is due to the presence of red corpuscles. 

One of the most familiar examples of this form of hyperaemia 
is that condition of the vessels of the lower extremities accom- 
panying varicose veins. Here all stages of the process can be 
studied. At first there is only oedema, the change in color being 
but slight, owing to the collateral circulation. Later there is 
considerable pigmentation of the skin, owing to the destruction of 
the escaped red blood-corpuscles, and finally the disturbance in the 
nutrition of the part is so great that a breaking down of the 
tissues takes place and gives rise to ulceration. Many of these 
symptoms Can be made to disappear by overcoming the obstruc- 
tion due to the dilated and tortuous blood-channels, which can 
easily be done by placing the limb in a horizontal posture. 
Passive hyperaemia may also be produced by pressure on venous 
trunks from inflammatory new formations or tumors. 

If the force of the blood-current is naturally weakened, as in 
feeble individuals or in disease of the heart, there may be local 
congestion at points where it is most difficult for the blood-column 
to overcome the force of gravity. This congestion often occurs in 
the lungs when an enfeebled individual has been for a long time 
in the recumbent posture, for then the blood-pressure is always 
more feeble. These forms of hyperaemia are known under the 
name of hypostatic congestion. It is possible that such congestions 
may take place in other internal organs, such as the prostate and 
bladder. It is necessary to be on guard against complications of 
this kind when confining the aged to bed for any length of time. 
A similar condition is that which leads under similar circum- 
stances to decubitus or bed-sore. Light pressure on a spot for a 
considerable time causes an ischaemia which is followed by a 
relaxation of the vessels, particularly the small veins, owing to 
the feeble circulation, instead of the usual hyperaemia that in the 



HYPEREMIA. 91 

normal condition should follow. The most protruding portions of 
the skeleton posteriorly indicate the points where these congestions 
are likely to occur. The feeble circulation is followed by stasis in 
the capillaries, the stage preceding actual death of the part, which 
stage may occur in the form of ulceration or gangrene. The 
bluish color imparted to portions of the body subjected to great 
cold is due to hyperaemia following an ischaemia of the part. In 
parts which have been in a state of chronic inflammation slight 
external influences will produce the cyanotic color for the same 
reason. The hyperaemia and swelling in legs convalescing from 
fracture is in part due to passive hyperaemia. In heart disease 
there may be general passive congestion of the whole body, as 
well as anaemia, and in shock the pallor, the clammy and 
cyanotic skin, are all due to a feeble heart-action which slackens 
the blood-current in the capillaries and the veins. 



IV. SIMPLE INFLAMMATION. 

i. The Process. 

A proper understanding of the phenomena of inflammation 
may be said to be absolutely essential as a basis upon which to build 
up a knowledge of surgical pathology. The close relation of the 
blood-vessels to the inflammatory process was recognized by Hunter, 
who says: k ' The act of inflammation would appear to be an increased 
action of the vessels. " He recognized the congestion of hyperaemia 
accompanying inflammation "as the first act of the vessels when the 
stimulus which excites inflammation is applied." 

In a study of the circulation as observed in inflammation, the 
experiments of Cohnheim, both on the circulation and the 
action of the white corpuscles, first published in 1867, added 
greatly to the knowledge of this process, and deserve, therefore, to 
be mentioned first. Such modification of his views as were sug- 
gested by other observers will be then considered. If a frog be par- 
alyzed with curare, and there is drawn through an incision made 
on one side of its abdomen a loop of intestine, and so spread out 
that the light can easily be transmitted, there will be obtained a 
transparent, highly vascular membraue which soon becomes in- 
flamed upon exposure to the air. It does not require very careful 
observation to perceive that the rapidity of the flow of blood is 
greatly increased, and that the number of the vessels is also appar- 
ently increased, many now being visible which were not before 
observed. The capillaries, through which there flowed only 
occasionally a corpuscle, are now quite full and their situation 
easily determined. The increased rapidity of the flow lasts only 
for a short time, however, and it is followed by a slowing of the 
current, which now becomes slower than normal. Thus far, the 
phenomena observed have not differed in any way from those seen 
in active hyperaemia ; but now a new element, the slowing of the 
current, is introduced, and from this time on the picture changes, 
and new phenomena are seen which have not been found to exist 
in hyperaemia. In consequence of the slowing of the current the 
corpuscles accumulate in great numbers in the capillaries, which, 
although distended, do not become materially increased in calibre. 

92 



SIMPLE INFLAMMATION. 



93 



Along the walls of the small veins there may now be noticed an 
accumulation of white corpuscles. They are no longer swept back 
again into the current after a temporary adhesion to the wall, but 
remain attached to the wall until a considerable number have 
accumulated. Occasionally one is dislodged, only to be soon 
arrested again in its progress. Finally, their number becomes so 
enormously increased that the entire vessel-wall appears to be lined 
with a layer of white corpuscles (Fig. 23). Adherence of white 
corpuscles to the wall is observed also in the capillaries, but there 
they are more freely mingled with the red corpuscles, whereas in 
the veins the two varieties of cells seem 
to have separated from one another. In 
the arterioles there is a tendency to ac- 
cumulation on the inner wall of white 
corpuscles, this being particularly no- 
ticeable during the diastole ; the suc- 
ceeding wave, however, sweeps them 
back into the current again, and they 
disappear. 

Presently slight protuberances are 
noticed here and there on the outer 
walls of some of the small veins, and 
they gradually increase in size. At cor- 
responding points on the inner side of 
the vessel are situated white corpuscles. 
At points favorable for observation one 
can see that an enlargement of the outer 
protuberance keeps pace with a dimi- 
nution of the size of the corpuscle pre- 
viously observed attaching itself to the inner wall, and that when 
the corpuscle has entirely disappeared there is seen on the outer 
wall a perfectly-developed cell, which proceeds to detach itself from 
the vessel and by frequent changes of shape to change its position 
from time to time. When at rest these cells are round, granular 
bodies, containing one or more nuclei, and are not to be distin- 
guished from white blood-corpuscles ; when in motion they possess 
one or more prolongations and become quite irregular in shape, 
resembling in all respects the ' ' wandering cells ' ' of the connec- 
tive tissue originally described by Recklinghausen. In the mean 
time large numbers of similar cells are making their way through 
the walls of all the veins within the field of vision until they are 
surrounded with several layers of white corpuscles. 




Fig. 23.— Blood-vessel, Mesentery 
of a Frog, showing diapedesis of leu- 
cocytes. 



94 SURGICAL PATHOLOGY AND THERAPEUTICS. 

The white corpuscles are also seen escaping through the walls 
of the capillaries, but to a less extent ; and there is found here 
mingled with them a certain number of red corpuscles. In the 
arterioles no such passage of cells is taking place, the interior of 
the vessel-wall, as has been stated, being kept clear of white cells 
by the force of the current. At the same time there is consider- 
able exudation of fluid from the vessels into the meshes of the 
surrounding tissue. The mesentery is now distended by a mass of 
cells and fluid, which presently escapes from the tissues to the sur- 
face, where the fluid coagulates and forms a membrane, between the 
fibrils of which are imprisoned the white and perhaps also some 
red corpuscles. The escape of white corpuscles from the vessel 
was first described in 1841 by Dr. Williams in England, but it 
was not until Cohnheim had so clearly demonstrated the process and 
its bearing upon the theory of inflammation that it was accepted 
by the scientific world. 

The tongue of the frog, in which has already been observed the 
changes of hyperemia, is also well adapted for studying the con- 
ditions of the circulation in inflammation. A caustic substance of 
some kind applied to the centre of the organ will enable one to 
observe different degrees of inflammation at different distances from 
the point of injury. On the extreme periphery the circulation is 
normal ; next, a zone of dilated vessels with slowing of the 
current, and, still nearer, an exudation of white corpuscles is 
seen, particularly from the veins. As the centre is approached the 
circulation becomes slower and the exudation greater, until the 
zone of stasis is reached where the vessels are acted upon by the 
chemical substance and the blood has coagulated in them. 

The different phases of the circulatory disturbances may be 
produced by simply placing a ligature around the frog's tongue 
and removing it at different periods of time. If left on from 
twelve to twenty-four hours, and then removed, a passing hyper- 
semia is produced. This can be seen on any limb after the re- 
moval of an Esmarch bandage. If the ligature is left in place 
from thirty-six to forty-eight hours, there is caused at first a 
hyperemia, followed by a slowing of the current and an exudation 
of cells and plasma. If left on for sixty hours, the stream will 
become so sluggish that there will be an enormous diapedesis of 
white corpuscles, and many red corpuscles will also be found in 
the exudation. The tongue looks as if it were covered with red 
spots. If the ligature be not removed for two or three days, the 
blood penetrates into the beginning of the arteries, but not into 



SIMPLE INFLAMMATION. 95 

the smaller arteries or capillaries or veins, and the circulation is 
never re-established. 

It is quite evident that there is here something different from 
simple hyperaemia ; not only is the current slower, but there is an 
exudation or a leakage through the walls of the vessels. This 
exudation is attributed by Cohnheim to a molecular change in the 
vessel- wall, a condition bringing about different relations of friction 
and adhesion between the blood and the walls due to changes in 
the endothelium. Cohnheim thinks that he can exclude the nerves, 
for he has been able to produce inflammation in the ear of a rabbit 
when every connection has been severed except the artery and the 
vein. This, however, can hardly be received as satisfactory evi- 
dence, for the perivascular ganglia are not excluded, and it is 
probable that in a case such as this they may be called into action. 
The dilatation is also greater than in hyperaemia ; for instance, a 
rabbit's ear will have a still greater dilatation and injection of the 
vessels after section of the sympathetic if the part be irritated with 
croton oil or dipped in hot water. The slowness with which the 
process develops is against the hypothesis of nerve-action ; some- 
times hours elapse after application of a caustic before any change 
occurs. 

Cohnheim argues, also, that the disturbance is not in the blood, 
for it may be produced in the tissues while the blood is absent. If 
the blood be excluded from a rabbit's ear by an Esmarch bandage, 
and the ear be dipped in moderately hot water, and the ligature be 
removed as soon as the ear has cooled off, the symptoms of inflam- 
mation will presently show themselves, and the ear will become 
swollen to several times its normal thickness. The disturbance 
has not been produced in the blood, but in the part itself. It is 
not probable, he thinks, that the cells of the part can have any 
influence upon the corpuscular elements of the blood, although it 
can be conceived that they may attract to themselves the fluid 
portion. He is therefore driven to the conclusion that the change 
is in the wall of the vessel. It has already been noted that if the 
blood is excluded from the vessels for a certain length of time, it 
will not enter them again, although the vessels are apparently 
open. It would not, therefore, be difficult to understand how under 
other circumstances these walls can hinder or retard the flow of 
blood. The chemical character of the fluid which filters through 
the wall, as compared with that observed in hyperaemia, is another 
reason for assuming a change in the wall. 

This idea of change in the vessel-wall is accepted by Burdon 



96 SURGICAL PATHOLOGY AND THERAPEUTICS. 

Sanderson. The vessels dilate, he says, because they have lost the 
power they before possessed of resisting dilatation. There is a 
loss of vital power, in consequence of which leakage also takes 
place. Professor Glax of Graz showed that by keeping up the 
vital properties of tissues in animals by the artificial circulation of 
properly arterialized blood through the vessels under an absolutely 
constant pressure, the introduction of a small percentage of injurious 
substances, such as metallic salts, produced a leakage and a dim- 
inution in the quantity of blood flowing through a given part. 

Landerer contends that the primum movens in inflammation, or 
the first thing to-be noticed, is the much more frequent injury to 
the tissue-cells than to the vessels. He would not do away entirely 
with the view that the vessel-wall takes part in the process. The 
capillaries should be regarded as vascular spaces in the tissues 
lined with endothelium like the lymph-spaces, and not as separate 
tubes sufficiently strong to support all the pressure that may be 
brought to bear upon them from within. The greater part of the 
tension is borne by the tissues, which, in virtue of their elasticity, 
can be placed in a state of elastic tension in the same way as the 
walls of larger arteries. The irritant ] — or, as Landerer prefers to 
call it, the u innammation-excitor ' ' — exerts an influence upon the 
tissues in virtue of which they become relaxed ; they are thus 
more easily distended and their elasticity is less complete. This 
diminished elasticity of the tissues would act upon the momentum 
transmitted to the blood in the same way as the wall of an athero- 
matous artery. The pressure cannot be returned to the blood- 
column, but must be expended in stretching the tissues. The 
momentum of the blood-column is thus partly lost and diverted to 
other purposes. The amount of blood increases, but the power to 
move it diminishes ; there is a leakage of lymph, owing to the 
diminution of external pressure. Landerer thinks that the old 
phrase, ubi stimulus ibi affluxus, which has something mysterious 
about it, should be discarded, and it should be replaced with the 
simple physical law of "local diminished pressure or resistance, 
increased flow." 

One of the earliest theories about the circulation was called the 
" attraction theory," which assumed an increased adhesiveness in 
the elements of the blood to one another and to the vessel-wall. 
Another theory assumed a change in the plasma by which it 
became more concentrated, and thus caused resistance to the natu- 
ral blood-flow. Or it was thought that there was a vital attraction 

1 Landerer rejects the term " irritation " as too suggestive of nerve- or muscle-action. 



SIMPLE INFLAMMATION. 97 

of the tissues for the blood : an increase of this function would hold 
back the blood in the tissues and produce a determination of blood 
to an organ. An affinity between the fluids of the tissues and the 
contents of the vessels undoubtedly exists. A change, therefore, 
in the tissues would affect the blood and the vessel- walls. The 
action of the cells in inflammation and their power to attract 
materials from the blood was especially dwelt upon by Virchow. 

Recklinghausen does not accept the experimental evidence 
showing a slowing of the current in inflammation. At the height 
of the process the color of an inflamed part is scarlet. The color 
of the blood when drawn by leeches is arterial, and the flow after 
an incision is more rapid. The pulsation of large arteries is 
stronger near an inflamed part, and the blood flows away as rapidly 
as it comes, as is shown in cases of venesection, where the blood 
from the vein has frequently also an arterial color. The stasis 
seen in the web of a frog's foot as the result of an " irritation " is 
not, he maintains, a symptom of inflammation. The irritant 
always produces at first an increased rapidity of the stream. When 
very small injuries are produced, there is no slowing of the stream; 
after a few hours the normal circulation is restored. If strong 
irritants are used, there is always a zone of "active congestion" 
or increased rapidity of flow of the blood surrounding the spot. 
The stasis in the centre leads to necrosis, a result which does not 
necessarily form a part of inflammation. The purulent softening 
which occurs around the necrosed portion takes place in the zone 
of active congestion. In the mesentery of the frog, as Reckling- 
hausen shows, there are many complications which produce a 
slowing of the current. Among these complications may be 
mentioned the thinness of the membrane exposed to the air, the 
contraction of the intestine, the great hyperemia of the abdominal 
viscera, and the diminished heart-action and blood-pressure caused 
by curare. In the frog's tongue which is turned over and 
stretched out there are frequent obstacles to the blood-flow. 

Recklinghausen evidently does not regard the slowing of the 
blood-current as a necessary part of inflammation. He is, how- 
ever, willing to admit that some inflammation-excitors may act 
through the blood upon the vessels, and thus impair the action of 
their walls. 

At all events, it may be concluded, from the experiments 
described above, that there is produced a condition differing from 
simple hyperemia. The disturbance of circulation in inflamma- 
tion comes on later and lasts longer than in hypersemia. There is 

7 



98 SURGICAL PATHOLOGY AND THERAPEUTICS. 

also exudation which does not occur in hypersemia or occurs only 
to a slight degree. 

In its earliest stages the congestion of inflammation differs 
probably but little from active hypersemia. As the process 
develops there is a greater dilatation of the vessels and a dimi- 
nution of tension; the vessel-walls and the tissues are "relaxed" 
through the action of the inflammatory agent. As a consequence, 
the conditions of hyperemia are so far departed from as to produce 
a leakage of the vessels. Should the inflammatory agent occasion 
a more profound impression upon the part, there may be a 
temporary stasis in some of the capillary vessels; and there can 
easily be imagined permanent stasis in a very limited area with- 
out the occurrence of necrosis 01 even of serious disturbance of 
nutrition. 

In the average case of pronounced inflammation there probably 
exists the phenomena of genuine hyperaemia of the blood-vessels 
in the peripheral portions of the inflamed mass, with greater 
distention and relaxation of the vessel as the centre is approached. 
These causes, combined with the swelling of the parts, would 
undoubtedly impair the rapidity of the blood-flow. The phe- 
nomena of a rapid current, as arterial pulsation and color, with 
more rapid flow of blood from an incision, might coexist with a 
slowing of the current in another portion of the same part. 

It is a well-known fact that in certain inflammations the con- 
gestion may be so severe as to obstruct the circulation of a con- 
siderable area, and to an extent that will cause death of the part 
or mortification. Such severe forms of inflammation are, however, 
fortunately, extremely rare, and they occur usually in parts not 
capable of rapid distention, as the bone, or where the circulation 
is less active, as the extremities of the arterial circuit. The 
disturbances of circulation of the blood seen in laboratory inflam- 
mations must, therefore, be regarded as partly artificial in cha- 
racter. In reality, however, there is probably considerable varia- 
tion in the rapidity of the blood-flow. 

A word may be said here about the changes seen in the 
blood during inflammation. Much attention has been drawn of 
late to the so-called u third corpuscle," which is a colorless proto- 
plasmic disk from 1.5 to 3.5// in diameter, these corpuscles num- 
bering, according to Osier, about one to every twenty red cor- 
puscles. They are visible in the circulating blood, and on the 
withdrawal of blood from the circulation they tend to adhere to 
one another, and to form irregular granular clumps, known as 



SIMPLE INFLAMMATION. 99 

"Schnltze's granular masses," or as granular debris so often seen 
in the neighborhood of blood-clots. The name now usually given 
them is "blood-plaques." Their tendency to agglutinate and to 
disintegrate has prevented their earlier recognition. They are 
more numerous in the infant and in the aged. They are supposed 
by some to be true hoematoblasts — that is, bodies from which the 
red corpuscles are formed ; they are seen in large numbers when 
blood-corpuscles are forming, but their relation to this process is 
still doubtful. 

The blood-plaques are much more numerous, however, in acute 
sthenic fevers and in chronic wasting disease, and probably also in 



«f% 



,#> 



*■■&. 



V^ 






cm ry 






^ 



* ** % H- # 



k 



i * 



Fig. 24. — Leucaemic Blood, showing various forms of leucocytes. 

cases of inflammation, both acute and chronic. At the crises of 
fevers and after the healing of acute abscesses they are seen in 
large numbers, and it is supposed by some that an effort at the 
repair of the blood is thus made by these bodies at this period, but, 
as has been said, the evidence on this point is yet insufficient. 
There is a very noticeable increase in the number of white cor- 
■w puscles in the blood during inflammation. This increase is what 
J should naturally be expected from observation of the great in- 
crease in the number of these cells in the inflamed part, and from 
the active migration which takes place through the walls of the 
blood-vessels (Fig 24). The whole system thus appears to sympa- 



IOO SURGICAL PATHOLOGY AND THERAPEUTICS. 

thize with the local condition, and those organs in which leucocytes 
abound, as the spleen and the lymphatic glands, are found much 
enlarged at this time. Davidson of Edinburgh explains the increase 
of leucocytes in the blood by a muscular contraction of the spleen, 
such as occurs in digestion through reflex action from the stomach ; 
in inflammation the source of the reflex irritation is supposed by 
him to originate in the walls of the arterioles of the inflamed part. 
These cells appear to be quite independent of the red corpuscles, 
which were formerly supposed to be derived from them. It will 
presently be seen that they have quite different functions, inti- 
mately connected .with the process of repair and the protection of 
the body from invading organisms. 

Leucocj^tosis is usually seen in the suppurating forms of inflammations, 
and is of value as confirmatory evidence in the diagnosis of deep-seated 
abscesses, even the pus of a felon being sufficient to cause marked increase 
in white cells. According to the observation of R. C. Cabot, it is regularly, 
though not invariably, present in purulent but not in catarrhal appendicitis, 
and is of value in enabling the physician to distinguish this affection from 
colic or from constipation. Leucocytosis may help one to distinguish pyo- 
salpinx and pelvic abscess from pelvic neuralgias and small ovarian tumors. 
Cabot did not find leucocytosis following urethral fever or cystitis or endo- 
metritis. He found this condition of the blood in three cases of suppurative 
colangitis, but absent in two cases of gall-stones without pus. Leucocytosis 
was not observed in tubercular affections. In general septic peritonitis it is 
occasionally absent. It is seen in suppurative osteomyelitis, and also in all 
forms of suppuration with pocketing of pus following operations. It is the 
rule in en~sipelas. In new growths it is very variable, apparently accom- 
panying chiefly those cases in which cachexia is most marked. 

In old times, when venesection was a common procedure in 
inflammatory disease, it was well known that blood coagulated 
quickly when withdrawn from the body. The so-called " buffy 
coat," the crusta phlogistica, or white layer, which was seen at the 
top of the coagulum in a vessel, was supposed to be due to an 
excess of fibrin in the blood ; a fibrinous crasis was supposed to be 
evidence of an inflammatory state of the blood. It is now known 
that the white corpuscles play an important part in the process of 
coagulation. Fibrin is formed by the union of two substances, 
fibrinogen and paraglobulin, with the co-operation of fibrin-fer- 
ment. Fibrinogen is found in the blood-plasma, while the other 
two substances are, for the most part, found in the white corpus- 
cles. When the latter break down these substances are set free, 
and are able to act upon the fibrinogen and form fibrin. The 
increased amount of fibrin seen in the coagulum and in the exuda- 
tions must be ascribed, therefore, to the increased number of white 



SIMPLE I NFL. I MM. I WON. 



101 



corpuscles circulating in the blood and finding their way into the 
tissues of inflamed parts. 

There is now to be considered the action of the tissues of the 
inflamed part. Before Cohnheim's and Recklinghausen's investi- 
gations the increased number of cells found in inflamed tissues 
was supposed to be due to a proliferation or a multiplication of 
the cells of the part. This was the view of Virchow, who showed 
that the tissue-cells are placed in a condition of increased activity 
by the inflammatory irritant, and consequently attract to them- 
selves nutriment in unusual quantity for their growth and multi- 
plication. The vascular changes in inflammation he regarded as 
the result of this increased activity of the cells. 

In connective tissue there exist two principal varieties of cells 
— the fixed and the wandering cells: the former are stellate or 
fusiform, and lie hidden 
among the fibres which 
constitute the principal 
portion of the intercellular 
substance. In addition to 
these there are the small 
round cells, containing one 
or more nuclei and a gran- 
ular protoplasm, in all re- 
spects resembling the white 
corpuscles of the blood. It 
was Recklinghausen who 
first recognized their 

power to take on changes of shape, such as are characteristic 
of the amoeba, and by this amoeboid movement (Fig. 25) 
to change their location. These cells, described by him as 
wandering cells, are constantly moving through the meshes or 
lymph-spaces of the tissues, entering them from the vascular 
system and escaping through the lymphatics, keeping up in this 
way a constant circulation. In the normal tissues they are few in 
number, and are seen and studied only after careful methods of 
preparation, but when the tissues are irritated or inflamed they are 
found there in large numbers, and their presence is accounted for 
in the way which has already been described when studying the 
action of the vessels in inflammation. In consequence of these 
observations Cohnheim assumed that the old theory of cell-prolifera- 
tion would have to be abandoned in favor of the migration theory. 
He endeavored to show that the fixed cells of the part underwent 




Fig. 25. — Amoeboid Movements of a Leucocyte. 



102 SURGICAL PATHOLOGY AND THERAPEUTICS. 

no active change during the inflammatory process, and for this 
purpose made a series of investigations upon the cornea, a form of 
tissue simple in composition and convenient for study, owing to its 
great transparency. The cornea when examined fresh in a drop 
of aqueous humor is seen to be absolutely transparent, and no 
structure can be distinguished, but when treated with a solution 
of chloride of gold a beautiful network of large stellate anastomos- 
ing cells is seen lying in a transparent intercellular substance. If, 
however, the cornea be treated with a solution of nitrate of silver, 
the cells appear as a branched system of canals anastomosing in a 
dark background. Such pictures as these suggest the presence of 
spaces through which it would be possible for wandering cells to 
migrate. It will be well to devote a moment to the consideration 
of these experiments, as the results obtained by Cohnheim have 
been the object of much discussion and dispute. They were, in 
brief, as follows: A ligature is drawn through the bulb of a 
rabbit's eye, and opacity of the cornea is seen in twenty-four hours, 
in frogs in from two to six days. Later, the cornea becomes milk- 
white or grayish or yellowish-white, and thicker and somewhat 
softer than in the normal condition. This opacity is due to leuco- 
cytes. On removing the cornea before the opacity is too great, 
and putting it into a neutral solution on an object-glass and 
examining it with a high power, the leucocytes are seen in all 
shapes, and also the corneal cells with their characteristic prolon- 
gations. The leucocytes may be seen moving about independently 
of these cells, and generally obscuring them. If, however, the 
cornea is treated with chloride of gold, the corneal cells are seen 
unchanged. Such changes as have been observed in them by 
others Cohnheim regards as degenerative only in nature. There is 
a granular condition of the protoplasm, a retraction of the prolon- 
gations, and the formation of vacuoles. If the centre of the 
cornea of a winter frog is touched with a pencil of nitrate of 
silver, at the end of twenty-four hours an opaque streak is seen 
projecting from the margin of the cornea in one or two places, 
generally from the upper and lower margins, at which point more 
or less hypersemia of the vessels is seen to exist. These opacities 
reach the cauterized point on the third day, and by the sixth day 
the opacity has localized itself around the cauterized point, while 
the surrounding cornea is clear. Under the microscope the 
corneal corpuscles were found by Cohnheim in all cases to remain 
unchanged, the opacity being due to the presence of large 
numbers of leucocytes. 



SIMPLE INFLAMMATION. 103 

One of the peculiarities of the leucocyte, about which more will 
be said later, is its power to appropriate foreign substances, which 
thus become imprisoned in its protoplasm. Cohnheim undertook to 
prove that the new cells seen in the cornea were identical with the 
leucocytes, by injecting granules of carmine or aniline blue, held 
in suspension, into the lymph-sacs and blood-vessels of the frog, 
and subsequently producing a keratitis. In such an inflamed 
cornea many of the new cells are found to contain these granules, 
which are not seen in uninflamed tissues. These views, first 
propounded by Cohnheim in 1867, produced a profound sensation, 
altering as they did very materially the then existing ideas of 
cellular pathology. It is needless to say that they met with active 
opposition from many quarters, but by no one were they so 
vigorously opposed as by Strieker of Vienna. This observer not 
only maintained the old theory of " proliferation," but developed 
it still further and evolved his theory of ' k tissue-metamorphosis, "" 
which, in brief, is that not only the cells, but also the entire 
tissue, returns to an embryonic condition and separates into 
amoeboid masses; in other words, that the intercellular substance 
as well as the cells may take part in the formation of new cells in 
inflammation. 

Many other observers also undertook to show that the fixed 
cells were capable of proliferation, and the cornea was selected for 
this purpose. Burdon Sanderson, while admitting that immigra- 
tion plays an important part in keratitis, pointed out that changes 
in the stellate cells of the cornea could be observed if studied at 
an earlier stage than that employed by Cohnheim. Shakespeare of 
Philadelphia recognizes four different kinds of cells in the cornea. 
His studies show pretty conclusively that the fixed cells are active 
in the processes of destruction and repair. He goes so far as to 
say that slight injuries of the cornea may be repaired entirely by 
these cells without the assistance of the adjacent blood-vessels 
other than an additional supply of blood-plasma. 

Finally, the following experiment would seem to leave little 
doubt that the corneal cells can proliferate. A cornea is irritated 
and then excised and preserved in a moist chamber; in two or 
three days a formation of wandering cells takes place at the point 
of irritation; the appearances of ordinary keratitis follow. It is 
certainly fair to infer that these cells came from the elements of 
the cornea existing there at the time of irritation. Recklinghau- 
sen states that changes in the corneal corpuscles have occurred 
under the eye of the observer, and that fragments of protoplasm 



104 SURGICAL PATHOLOGY AND THERAPEUTICS. 

separated from them have been seen to go through the same 
changes of form as wandering cells. 

In the omentum of young animals there is a very simple form 
of epithelium and one more or less remote from blood-vessels. If 
an artificial peritonitis be produced, Cornil and Ranvier have 
shown that an active proliferation of these cells will be seen at the 
>end of twenty-four hours. In the writer's own studies of inflamed 
tissue he has seen undoubted evidence of proliferation of the fixed 
cells. Some beautiful examples of this were observed in the skin 
adjacent to a carbuncular inflammation. In the inflammation of 
the walls of the artery of a horse, produced by the application of a 
ligature, the muscular cells of the media were seen in an active 
state of proliferation. Cohnheim in answer to observations of this 
kind pointed out that many of these changes seen in fixed cells 
were of a degenerative character and preceded the final destruction 
of the cell. 

The emigration theory still continued dominant, however, until 
Strassburger, Flemming, and others demonstrated the changes 
seen in the nucleus known as karyokinesis, or indirect cell- 
division,, which they observed in vegetable cells, in the tissues of 
the lower animals, and afterward in the normal human tissues, 
and finally also under pathological conditions. (See page 218.) This 
proved conclusively that the fixed cells did not play a passive part 
in inflammatory processes, and the role which these cells played in 
hypertrophy, repair, and tumor-growth (Fig 26) was shown to be a 
more prominent one than had hitherto been supposed. 

In any acute inflammation the tissue-cells break down in large 
numbers; but many of them, according to Ziegler, become 
wandering cells, and are difficult, at first, to distinguish from 
leucocytes. They do not produce any pus-corpuscles, but event- 
ually play a prominent part in the process of repair. 

Several forms of leucocytes are now recognized in inflammatory 
tissue, among them being the single and the polynucleated. The 
polynucleated are the type of the pus-corpuscle. They possess 
two or three nuclei or peculiarly deformed biscuit or sickle-shaped 
nuclei, which are supposed to be appearances which precede a 
breaking down of the cell (Fig 24). The single-nucleated cells 
are scarce in acute inflammation, but in the later stages and in 
chronic forms they are more common. 

Many of the wandering cells derived from connective-tissue 
cells closely resemble the single-nucleated leucocytes, and cannot 
always be distinguished from them. 



SIMPLE INFLAMMATION. 105 

Regarding the origin of many of the cells seen in inflamed 
tissues, Grawitz has recently propounded a theory which closely 
resembles that already alluded to by Strieker. He claimed that 
the majority of these cells came from the intercellular substance. 
According to this theory, during embryonic development numer- 
ous cells change into intercellular substance and remain slumber- 
ing, as it were, in this condition until some irritation arouses them, 
when they return again to an active-cell type. This means that 
the fibrous tissue of connective tissue, the homogeneous tissue in 
cartilage, and the intercellular substance in bone are not excretory 



Wi 



w 



•« 



* 





Fig. 26. — Karyokinesis in the Cells of a Sarcoma. 

products of the cells, but that the bodies of the cells are actually 
changed into intercellular substance. 

When these cells begin to appear the nuclei are extremely 
small and the cells seem to have no protoplasm. They are 
arranged in rows, and are so deeply situated in the bundles of 
fibres that one must conclude that they have originated in loco 
from their accustomed quiescent fibrous state, and cannot therefore 
have been transported thither by emigration. These cells are 
frequently seen in numbers when there is no sign of karyokinesis, 
indicating that the pre-existing cells of the tissue are not in an 
active state of development; which fact goes to show that they are 
not derived from other cells. The nuclei gradually enlarge, and 
acquire a cell-body that forms around the nucleus from the 



106 SURGICAL PATHOLOGY AND THERAPEUTICS. 

material of which the softening fibre is composed. When a 
considerable portion of the intercellular substance has changed to 
cell-protoplasm the fibre as such disappears, and it is replaced by a 
row of cells lying close to one another. These cells when once 
formed are precisely like those which existed before, and, like 
them, are capable of proliferation. 

Shakespeare, whose work has already been alluded to, regards 
the flat or spindle-shaped cells seen in the primary bundles of fibres 
in the cornea, the cartilage, or the intima of vessels as cells which 
are usually invisible and which are not susceptible to staining 
processes. These cells, he thinks, are Grawitz's slumbering cells. 
Under the influence of irritation these cells are aroused to activity, 
and appear to acquire their original power both to destroy and to 
repair. Weigert vigorously opposes this idea of slumbering cells. 
The fibres, he says, are absorbed, being damaged or dead, and cells 
appear where they were before. The new cells come from the pro- 
liferation of the pre-existing cells. The absence of the signs of 
mitosis, or indirect cell-division, is no argument against their 
origin from the cells of the part, as this form of division is chiefly 
confined, to cells that are intended as permanent cells. 

What are the functions of the leucocytes? and why do they 
crowd in such numbers to the inflamed part? Cohnheim regarded 
them as the active agents in the process of repair, but according to 
Ziegler many of them are taken up by the proliferating connec- 
tive-tissue cells, for which they appear to serve as nutriment. 
Many of these mobile cells appear to play the role of scavengers, 
owing to the power possessed by them of appropriating particles 
of foreign bodies or bacteria and transporting them to distant 
points. The usefulness of the leucocytes in consuming and 
receiving portions of the broken-down tissue can easily be under- 
stood, for there is here touched the principle of absorption, by 
means of which dead substances, blood-clots, and exudations are 
disposed of. 

A new view of the function of these cells seen in inflamed 
tissue has been propounded by Metschnikoff, whose first studies on 
the action of the daphnia when attacked by the spores preying 
upon that organism formed the basis of his doctrine; which is, in 
brief, that the cells of the inflamed part and the invading organ- 
isms are opposed to one another in a struggle for existence. If the 
white corpuscles, or the phagocytes, are enabled to appropriate and 
to destroy the bacteria with which they come in contact, the 
system is protected from the germ; if, however, the bacteria are 



SIMPLE INFLAMMATION. 107 

more powerful than the cells, a destructive local inflammation or a 
constitutional disease may result. MetschnikofF describes two 
kinds of phagocytes — the microphagocyte and the macrophagocyte. 
The former corresponds to the migrating leucocyte, and the latter 
are larger cells developed from the proliferated fixed connective- 
tissue corpuscles, which in some cases consume the smaller cells 
after their struggle with the bacteria, thus removing the debris of 
the inflammatory struggle and paving the way for an absorption 
of its products. In other cases they attack the bacteria directly: 
they are, for instance, more likely to take up bacilli, as in anthrax 
and leprosy. In tubercle the macrophagocytes figure as epithelioid 
cells and giant-cells containing bacilli, but these organisms are 
seen also in the leucocytes. 

This doctrine is well illustrated by studies made by its author 
in erysipelas. He finds that in fatal cases of this disease only 
comparatively few leucocytes were seen, and none containing 
bacteria. In the cases recorded some of the cells contained a large 
number of the bacteria; other cells contained none. In some of 
the former there were perfectly-formed bacteria; in others the 
bacteria did not take the staining reagent so well, showing a 
degeneration of power; and in others granular debris only of 
bacteria was found. In gangrenous portions of erysipelatous 
tissue no cells containing bacteria were seen, the microbes all 
being free in the tissues. 

Experiments made with the anthrax bacillus on animals not 
susceptible to this disease show well the action of the leucocytes, 
as this form of bacteria is so large that the organisms are studied 
with comparative ease. 

In some diseases the macrophagocytes appear to be the active 
cells; in others the microphagocytes destroy the bacteria. Many 
observers have not accepted this doctrine, and they maintain that 
the loss of activity of the bacteria is either a spontaneous loss or 
one due to the antagonism of other forms of bacteria. Baumgarten 
points out that in relapsing fever the spirilli are not seen in the 
leucocytes, yet the patient recovers. The explanation of this is, 
probably, that the strife is not waged in this case in the blood, but 
in the tissues or the viscera, as the spleen. At all events, there is 
seen, in this doctrine, although it is as yet hardly removed from 
the stage of probability, a reasonable explanation of that condition 
known as immunity, by means of which certain animals are pro- 
tected from certain diseases, and by which man is also protected 
from a second attack of certain diseases. 



ioS SURGICAL PATHOLOGY AXD THERAPEUTICS. 

A word in conclusion regarding the action of the cells in 
inflammation. The number of cells found in an inflamed part is 
in proportion to the degree of inflammation existing there. If, on 
the one hand, the inflammation has been severe, the tissues will be 
found so filled with small round cells that it is difficult to recog- 
nize the original character of the tissue itself. If, on the other 
hand, the decree of irritation has been slight, as is often the case 
in wounds healing rapidly under aseptic treatment, a compara- 
tively small increase in the number of cells of the part takes 
place. 

Little has hitherto been said about the changes seen in the 
intercellular substance. In connective tissues this substance con- 
sists mainly of a network of fibres. In certain tissues, like carti- 
lage or the cornea, this substance is more homogeneous in appear- 
ance, although with suitable reagents the fibrous nature is made 
apparent. Under the stimulus of inflammation there is great 
increase in the number of cells which more or less obscure the 
intercellular substance; but it is evident that a solvent action is 
exerted upon it, either by the cells that are present or by the fluid 
which is exuded from the blood-vessels, or by both. According to 
Strieker, the cellular substance returns to an embryonic state and 
becomes separated into particles of amoeboid substances; in other 
words, it is broken up into cells again. According to most 
authorities, it is, however, simply melted down into a granular 
softened material, forming a matrix for the support of the vastly 
increased number of cells. When the cell-immigration is limited 
in extent there is seen but little change in the intercellular 
substance. 

In addition to the escape of leucocytes from the blood-vessels, 
there is found a certain amount of fluid which has leaked through 
the vessel-walls into the inflamed part. This fluid is richer in 
albumin and is more concentrated than the serum exuded in 
passive hypersemia. and it resembles closely the liquor sanguinis 
or blood-plasma. The fibrinogen it contains comes in contact 
with the fibrin-ferment and paraglobulin which are set free from 
the numerous breaking-down leucocytes, and fibrin is conse- 
quently formed. That this collection of fluid is not due to an 
obstruction of the capillaries can easily be demonstrated in a dog's 
leg by setting up an inflammation in the paw, exposing the 
lvmph-vessel, and inserting a canula into it, when it will be seen 
that a considerable increase in the amount of lymph naturally 
exuded by the vessels is taking place. The coagulation of the 



SIMPLE INFLAMMATION. 109 

lymph thus accumulated in the inflamed part gives to it a certain 
firmness which is characteristic. The product thus formed, with 
the cells which have emigrated from the blood-vessels, constitutes 
what is known as the exudation. 

Such, then, are the changes which take place in the tissues 
during the origin and development of a simple or uncomplicated 
inflammation. The further progress of the inflammatory process 
will be considered in the succeeding chapter. 



V. SIMPLE INFLAMMATION. 

2. Symptoms and Causes of Inflammation. 

Font cardinal symptoms of inflammation have from time 
immemorial been grouped together — namely, rubor, tumor, dolor, 
and calo)\ or redness, swelling, pain, and heat — to which modern 
writers have added a fifth, functio l<zsa, or disturbed function. 

In a typical case of inflammation — as, for instance, an acute 
cellulitis of the arm of a powerful laboring-man — these symptoms 
are all apparent even to the most inexpert observer. The scarlet 
redness of the skin; the great distention of the subcutaneous 
tissue, forming a diffused and tense swelling, pressure upon which 
shows rapid changes of color, as the temporary bleaching of the 
part is followed by a hue deeper than before; the exclamation of 
pain which even careful handling elicits from the patient; the 
greatly increased warmth of the arm as compared with that of 
its fellow; together with the complete loss of power of the 
diseased limb, — all combine to form a characteristic picture of 
disease. 

The rubor, or redness, is due to the increased determination of 
blood to the part. It differs from the color of hypersemia prin- 
cipally in the variability of its hue. This change is partly due to 
varying rapidity of the blood-flow. When the congestion is at its 
height the color is scarlet, and the blood, when drawn by leeches 
or when allowed to flow from an incision, is of a bright arterial 
color, and it is more rapid than normal. The tint deepens as the 
current slackens, and as the blood-column, moving slower, loses 
more of its oxygen. In very severe forms of inflammation, when 
the swelling is excessive and the parts are unusually tense and 
the capillaries are crowded with red corpuscles, there may be 
an escape of red corpuscles with the leucocytes through the 
walls of the vessels, and in such cases they are usually collected 
together in little groups, forming what are known as punctifc 
ecchymoses. This is the explanation of the so-called ' ' hemor- 
rhagic ' ' forms of inflammation, such as are seen in the erup- 
tions of some of the severe types of exanthemata, as smallpox 
and measles, 
no 



SIMPLE INFLAMMATION. Ill 

Usually the color is brighter at the periphery of an inflamma- 
tory swelling, and deepens toward the centre, where the current is 
more impeded in its action. As the blood flows more slowly it has 
the more livid or bluish hue seen at the termination of an inflam- 
mation when it passes from the acute into the chronic stage. The 
presence of an abundant exudation diminishes the intensity of the 
color, as the blood-vessels are then surrounded by a more or less 
colorless fluid or a semi-solid mass. If firm pressure be made upon 
such a spot, the part will assume a somewhat yellowish tinge, due 
to the presence of the exudation. This appearance, which is 
characteristic in acute inflammations of the skin, enables one to 
distinguish between a genuine inflammation in its incipient stage 
and the temporary blush due to pressure or to stimulating 
dressings. 

The color of an inflamed mucous membrane is much deeper 
than that of the skin, and is obviously due to the close proximity 
of the blood-vessels to the surface. The color is altogether absent, 
however, in bloodless parts, as in the cornea or the cartilage. In 
the latter cases, however, there is usually found congestion in the 
adjoining vascular tissues. A foreign body in the cornea will soon 
make its presence suspected by congestion of the vessels of the 
conjunctiva. The inflammation of the cartilage of a joint is 
accompanied by congestion of the vessels of the capsule of the 
joint, and sometimes even of the external integuments. 

The tumor, or swelling, the second symptom, will now be 
considered. It might be supposed that swelling was due to the 
same cause which produced the redness — namely, increased flow 
of blood to the part — but in active hypersemia there is no swell- 
ing, and in passive hyperemia the swelling is due, not to the 
increased current of blood in the part, but to dropsical effusion. 

If an incision is made into an inflamed organ, it will not only 
be found that more blood flows, but also that the tissues them- 
selves are more juicy. If an inflamed mucous membrane is 
examined, there will be found, at certain stages, an increased and 
altered secretion. In an inflamed pleural cavity a clear or slightly 
opaque fluid, containing colorless coagula, is observed. Even 
irritation of the skin, as in burning, will show that here too more 
lymph is formed, which collects on the surface beneath the 
epidermis in the shape of blisters. 

The exudation not only shows itself as altered secretion exud- 
ing from mucous membranes or as effusion into serous and syno- 
vial sacs, but a certain amount is retained also in the tissue itself, 



112 SURGICAL PATHOLOGY AND THERAPEUTICS. 

as in the capsule of the joint or in the mucous membrane of the 
throat, and produces swelling. The delicate areolar tissue of the 
eyelids or of the prepuce is often the seat of distention sufficiently 
great to cause alarm to the patient. Such tissues often swell 
when the seat of the inflammation is in an adjoining structure, 
such as the conjunctiva or the urethra. Dense organs when 
inflamed sometimes cause considerable collections of fluid in their 
vicinity. A portion of the "tumor" formed in "swelled 
testicle ' ' is due to effusion into the tunica vaginalis. The great 
swelling of the soft parts of a thigh, when the subject of an acute 
osteomyelitis of the femur, is due to the excessive exudation into 
the areolar tissue. Such unusual collections of lymph, manifestly 
of a fluid character, accompanying severe inflammations, are 
known as collateral oedema. 

Soft and spongy organs, when inflamed, however, become 
firmer. This fact is well illustrated by pneumonia, when the 
exudation, coagulating in the alveoli of the lung, gives it the 
consistency of the liver, the exudation being known as hepatiza- 
tion. Many of the forms of cellulitis are made manifest to the 
touch by the induration which the coagulated exudation produces. 
The outlines of such an inflammation are easily determined by 
gently holding the inflamed mass between the thumb and finger 
and moving it to and fro. The contrast with the surrounding 
flexible tissues is thus made apparent, and the " cake-like" hard- 
ening is a familiar condition, and a symptom often of value to the 
surgeon in diagnosis. A certain portion of such a swelling is 
possibly due to the proliferation of the cells of the part and to the 
formation of new vessels during the process of repair, but it is now 
known that much less swelling accompanies healing under strict 
aseptic conditions, and that the elements immediately involved in 
the reparative changes are not sufficiently bulky to cause an appre- 
ciable amount of swelling. This symptom in some cases may, 
indeed, be absent entirely, as in dense organs incapable of sudden 
changes or in organs so liberally supplied with lymphatics that the 
exudation may be absorbed almost as rapidly as it accumulates. 
Such is the case in many of the exanthematous inflammations of 
the skin. 

As has already been seen, the exudation consists of an unu- 
sually large formation of lymph, a fluid of high specific gravity 
and containing a considerable quantity of albumin, and also an 
accumulation of leucocytes which have emigrated from the blood- 
vessels. This material, when poured into the meshes of a tissue 



SIMPLE INFLAMMATION. 113 

or an organ, soon forms fibrin by coagulation, and imparts a 
certain hardness or induration to the inflamed tissue. 

The cause of this symptom of inflammation has been the sub- 
ject of much dispute. Why, under these circumstances, the blood- 
vessels should act so differently than in their normal condition is 
not easily explained. It is clear that there is greater permeability 
of the walls of the capillaries and small veins. This has been 
explained by assuming the formation of little holes or "stomata" 
between the endothelial cells lining these delicate tubes ; and this 
hypothesis has the sanction still of some of the highest authorities. 
Cohnheim attributes alterations of function to molecular change 
in the wall, or, as Sanderson expressed it, there is a damaged con- 
dition of the vessel which causes it to leak. Landerer with much 
plausibility points out that there is more tension in the tissues 
supporting the capillaries than is usually supposed, as can easily 
be demonstrated by injecting fluids subcutaneously. It is found 
by experiment to be greater than in the veins and lymphatics. 
Clinically, the great distensibility of the fibres is seen also during 
the formation of an abscess, and their relaxation is observed after 
pus has been evacuated, as shown by the wrinkled appearance of 
the skin. It is by such support as this tissue gives that the integ- 
rity of the capillaries is preserved in health. The tissues, being 
relaxed by the inflammatory condition, permit the passage of the 
exudation through the walls of the vessels. 

A sort of flooding of the tissues is produced by this process, and 
it is pretty generally agreed that this phenomenon has for its 
object the sweeping away of all injurious substances, whether 
chemical poisons, fragments of dead and injured tissue, or bacteria, 
and at the same time new materials are conveyed to facilitate the 
process of repair. The powers peculiar to the leucocytes or pha- 
gocytes when performing this duty, which enable them to act as 
scavengers and appropriate foreign particles and fragments of cells 
or tissue or injurious organisms of every kind, and the antiseptic 
properties of blood-serum, favor this view. The cures of many 
chronic diseased conditions by inducing an acute inflammation, the 
treatment of hydrocele by the injection of carbolic acid, or the 
obliteration of a chronic eczema by applications which produce a 
fresh inflammation, are all clinical illustrations of this protective 
influence of one of the apparently most alarming symptoms of 
inflammation. When, after an excessive inflammatory reaction, 
great swelling is followed by suppuration, it is seen that the old 
idea of a "peccant humor" rests on a scientific basis, and in the 



H4 SURGICAL PATHOLOGY AXD THERAPEUTICS. 

discharged contents of the abscess are found the remnants of the 
injurious substances which gave rise to the inflammation. 

The dolor, or pain, is due to the pressure in the terminal 
branches of the nerves, and consequently it differs greatly accord- 
ing to the distensibility of the part or to the amount of exudation 
or to the nerve-supply. The inability of certain tissues to yield to 
the inflammatory swelling probably is the cause of the most severe 
pain. The suffering produced by an "ulcerated'' tooth when 
deep-seated pus is endeavoring to reach the surface of the bone, 
and the pain from pressure caused by a felon, are sufficiently 
familiar examples. 

Pain is usuallv most severe at the beg-inning of an inflammation, 
while the tissues are in process of being stretched, or when the 
exudation takes place so rapidly that the tissues have no opportu- 
nity to yield gradually. It is possible that there may in some cases 
be an undue sensitiveness of the nerves. Hyperesthesia was 
observed by Claude Bernard in the ear of a rabbit after division of 
the cervical sympathetic. 

The throbbing sensation which so often accompanies acute 
inflammation may be due to the extra pressure exerted by the 
arterioles during systole upon the sensitive nerve-fibrils. Boring 
pains are usually associated with chronic inflammations of bone, 
and are at times a source of great misery to the patient. Lanci- 
nating pains, which accompany more acute swellings, are suggest- 
ive of an abscess approaching the moment of breaking and 
discharging its contents. 

Among some of the less severe forms of pain may be included 
soreness, generally characteristic of the furuncle. The soreness 
of a boil is proverbial. It means the formation of a small abscess- 
cavitv in a Yielding but suoerficiallv sensitive or^an. It is 
proverbial also that itching is considered a good sign; which is 
undoubtedly true, for when pain ceases the inflammation is 
probably subsiding, and this symptom of itching is due to the 
infiltration of the parts about the terminal nerve-branches. The 
itching will not disappear until this residue of inflammatory 
products has been absorbed. Some portions of the body are much 
more sensitive than others. An inflammation seated at one of the 
outlets of the body where the skin and mucous membrane join is 
always productive of great suffering. Painful affections of certain 
organs are often referred to distant points. Pain in the uterus is 
felt in the back, but pain in the back, due to caries of the 
Yertebra, is usually referred to the belly. In many cases of hip 



SIMPLE IX TLA MM. I Th W. 115 

disease the pain is felt in the knee. Pain in the heel has been 
described as characteristic of a variety of diseases. It has been 
known to accompany inflammation of so distant an organ as che 
prostate gland. 

Pain will often spread back along the course of a nerve, as if 
bv sympathy, to adjacent branches. The pain of an inflamed 
finger may not only involve the fingers of the hand, but may 
spread also to the shoulder and side. The teeth likewise furnish 
familiar examples of such anastomoses of pain. Pain may 
altogether be wanting. This absence of pain is the case in some 
nerveless organs, also in grave inflammation when the severity of 
the inflammation endangers the vitality of the part. 

The calor y or heat, is the last of the four cardinal symptoms. 
The increased warmth of an inflamed spot on the surface of the 
body is readily recognized by the hand of the surgeon, and a 
comparison with the corresponding spot on the other side of the 
bodv is thus easilv made. The old-fashioned theorv re^ardino- this 
symptom undertook to explain this rise of temperature by as- 
suming an increased chemical action in the part itself, by which 
action heat was produced, and that subsequently the superheated 
blood, being conveyed over the body, produced fever. But 
Hunter, who was the first to make thermometric observations on 
this point, came to the conclusion that a local inflammation was 
unable to raise the temperature of the part above that found at the 
source of the circulation. 

Hunter's experiment, which has been quoted by many writers, 
was upon a patient on whom the operation for the radical cure of 
hydrocele had been performed. On opening the tunica vaginalis 
he placed a thermometer in the wound, and found the instrument 
registered 92°: the next day the mercury in the instrument, intro- 
duced as before, rose to 9S- ; 4 C , being an increase of 6- ; 4 c in the 
twenty-four hours. 

Recent investigators endeavored to show that the inflamed 
part produced heat. John Simon found with the thermo-elec- 
tric needle, first, that "the arterial blood supplied to an inflamed 
limb was less warm than the focus of inflammation itself;" sec- 
ondly, l< that the venous blood returning from the inflamed limb, 
though less warm than the focus of inflammation, is warmer 
than the arterial blood supplied to the limb;" and, thirdly, 
"that the venous blood returning from an inflamed limb is 
warmer than the corresponding current on the opposite side of 
the body." These observations, which were put forward some 



Ii6 SURGICAL PATHOLOGY AND THERAPEUTICS. 

twenty-five years ago, were later confirmed by C. O. Weber, an able 
German observer. 

Claude Bernard, the distinguished French physiologist, found 
in his classical experiments on the ear of a rabbit after division 
of the cervical sympathetic, that the temperature of the ear 
became higher than that of the rectum, and Weber found that if 
the ear was irritated so as to produce a simultaneous inflammation 
the temperature would rise still higher. 

As already seen, however — and, indeed, as the experiment just 
quoted proves — simple active hypersemia of an external organ is 
always accompanied by a rise of temperature of the part, and this 
rise is due to the increased amount of warm blood which is carried 
there from the centre of the body. Observations on the tempera- 
ture of the different tissues and organs show that the production 
of heat originates chiefly in the muscles, and to a slight extent 
also in the viscera; but, although much heat is manufactured near 
the surface, the more external portions of the body by exposure to 
a lower temperature and by evaporation are rendered cooler than 
the internal organs. Cohnheim has experimentally demonstrated 
that much more blood flows through the inflamed leg of a dog 
than through the sound leg, and concludes, therefore, that the rise 
of temperature is due solely to the increased amount of warm 
blood flowing through the part. 

More perfect forms of thermo-electric apparatus have demon- 
strated also that although there is a considerable difference be- 
tween an inflamed spot on the surface of an animal and the 
corresponding spot on the other side of the body, as shown by 
inserting thermo-electric needles into the symmetrical parts, yet 
the farther the inflamed spot is situated from the surface the less 
is the difference found in the temperature of the two sides. In 
internal inflammations, such as pleurisy or peritonitis, it was 
found that the temperature is no higher than that in the healthy 
pleura or in the peritoneum or in the heart of the animal 
experimented upon; and these experiments have been confirmed 
by similar observations taken in deep-seated inflammations in 
man. 

The highest authorities have therefore concluded that the tem- 
perature of an inflamed part is in direct proportion to the amount 
of hypersemia of the part. Recklinghausen thinks that it may be 
possible that a fractional part of the heat may be produced by 
chemical changes going on in the inflamed tissues or by increased 
oxidation due to a removal of nerve-influence, but there is yet no 



SIMPLE INFLAMMATION. 117 

proof that any such local production of heat takes place. Modern 
observations have therefore been unable to disprove the truth of 
the doctrine which Hunter taught a century ago. 

In inflammations of certain parts of the body it is obvious that 
this increased heat will be wanting, as in the lung or the kidney, 
and it is only in superficial tissues, whose temperature is habitually 
lower than that of the blood, that it is most marked. The process 
is analogous to that of a hot- water radiator : the greater the amount 
of water of a given temperature flowing through the pipe, the 
greater will be the amount of heat given off ; the temperature of 
the radiator will never be quite so high as that of the boiler. 

To the four cardinal symptoms of inflammation above described 
there has of late years been added a fifth, which, however, might 
equally well be regarded as a result rather than as a symptom of 
the inflammatory process. This fifth symptom is the functio l<zsa, 
or impaired function of the part. 

It can easily be understood that a muscle which has been infil- 
trated with an inflammatory exudation, and which is hot, painful, 
and swollen, cannot act so readily as a healthy muscle. In such a 
case the muscle is found spasmodically contracted, and for the 
time being no relaxation of its tissue can take place. The sterno- 
cleido-mastoid muscle, which is often implicated in inflammations 
of the surrounding glands and cellular tissue, will sometimes cause 
considerable deformity by twisting the head, and the function of 
the muscle will not be restored until the inflammation has subsided. 
After fractures near joints there is seen great impairment of the 
motions of the joints, existing long after the bones have grown 
together, the tendons and capsules being more or less glued down 
and impaired in their natural movements by the exudation which 
has taken place around them and in the adjacent muscular tissue. 
Great dryness of the mouth accompanies inflammation of the 
parotids. The special senses are all impaired when the organs 
concerned in their function are inflamed : the eye cannot see, the 
nose cannot detect odors, and the ear cannot hear so well when 
inflamed as in health. Not only are the sensitive nerves pressed 
upon, but probably also those which conduct reflex actions, and 
likewise the motor and secretory nerves. The so-called ' ' trophic' ' 
action of the nerves is sometimes so impaired that the nutrition of 
the organ is seriously affected, and atrophy or permanent degenera- 
tion of certain structures may take place. 

As has been seen, each symptom of inflammation may be want- 
ing at certain times. The redness will not be observed in non- 



Ii8 SURGICAL PATHOLOGY AND THERAPEUTICS. 

vascular organs. The swelling will often be absent when the 
absorbents are sufficiently active to carry off quickly the exuded 
material, and there will be no material change in the temperature 
of the interior organs ; but as the surgeon ordinarily sees inflam- 
mation — that is, in the external portions — these symptoms are 
almost invariably present in acute inflammations. In chronic 
inflammations — namely, in those which are not accompanied by 
such active pathological phenomena as have been studied, and 
which last a long time — none of the symptoms are so well marked 
as they are in the acute forms ; many of the symptoms, such as 
heat, redness, and even pain, may altogether be wanting. There 
will always be found a certain amount of swelling or " thick- 
ening" of the part, or "induration." 

Before attempting to define inflammation it is well to have an 
understanding as to the precise seat of the process. As been seen, 
the pathological changes are confined chiefly to the blood-vessels 
and to the tissues. Virchow, in advancing his theory of cellular 
pathology, maintained that inflammation could not be produced 
if the tissues were not directly irritated either from without or 
through the blood, and that the cells were thus enabled to attract 
inflammatory products through the blood, the phenomena of 
inflammation being thus produced. This was known as the 
attraction theory. 

Cohnheim, whose studies on the action of the blood-vessels and 
the leucocytes have been quoted so often, regarded the wall of the 
smaller vessels as the seat of the lesion, and he assumed a molec- 
ular change in the vessel-wall to account for the series of changes 
which ensued, and which are distinctly different from those accom- 
panying simple hypersemia. 

Neither of the above theories has been accepted in its entirety, 
as further observation has shown that the areolar tissue is so inti- 
mately connected with the smaller vessels that the two structures can 
hardly be considered separately from a physiological point of view ; 
and it is difficult to conceive of a lesion affecting one without 
involving the other. Recklinghausen shows that the products of 
inflammation are so deep in the tissues and so little on the surface 
of membranes, but rather near the blood-vessels and the lymph- 
channels in the tissues, that the evidence is in favor of the view 
that the walls of the vessels and the surrounding tissues are the 
chief seats of inflammation. Different structures will of course 
be affected according to the route through which the inflammatory 
agent acts. 



SIMPLE INFLAMMATION. 119 

Most traumatic inflammations take their origin in the tissue, for 
they are directly acted upon by the knife, or in superficial injuries 
or contusions. The parenchymatous inflammations of the deeper 
organs — that is, the inflammations acting upon the cells which per- 
form the special function of the organ — are examples also of this 
form. 

Those inflammations which are conveyed through the blood 
affect those tissues which lie chiefly in the course of the vessels, 
and which, consequently, form the stroma or framework of organs, 
and are termed by the pathologist "interstitial." Typical exam- 
ples of this form are seen in the kidney, the liver, and the brain 
from alcohol-poisoning, but the surgeon has also to deal with this 
class of inflammations in cases of acute infective disease. 

Severe crushing injuries, strong chemical agents, or the effects 
of extreme heat and cold result in death of the part. Dead tissue 
frequently acts upon the surrounding tissues as a "foreign body," 
having become a source of infection. The agencies thus called 
into action exert themselves partly upon the tissues directly and 
partly on the vessels of the part. 

What, then, is the nature of inflammation ? The apparatus 
concerned in nutrition may, as has been seen, be so affected 
through the tissues or through the blood-vessels as to sustain an 
injury, or, as Sanderson expresses it, there occurs a "damage," 
which may result in death of the part, or, if acting less severely, 
may cause a series of changes such as has been described as cha- 
racteristic of inflammation. It has, in fact, been pretty generally 
agreed that inflammation is a disturbance of the process of nutri- 
tion, and this view is expressed by Van Buren, who defines it as 
"a condition located in the apparatus of nutrition, affecting a 
limited area, and consisting in temporary perversion of nutrition 
from its natural and regular order." Observe that he does not 
regard it as a disease, but as a "condition," and " in the majority 
of cases not even a morbid condition." It is, in fact, difficult to 
determine exactly where a physiological process ends and a morbid 
condition begins. The condition of a muscle after excessive exer- 
cise is one which presents the symptoms of inflammation, although 
in a mild degree. It is swollen and warmer than natural, more 
blood circulates through it, and every one knows that it can also 
be painful. The dividing-line between such a state and true inflam- 
mation, between the physiological and the morbid process, is not a 
broad one. Sanderson, however, does not even regard it as a dis- 
order of function, but as an arrest of function. The phenomena of 



I20 SURGICAL PATHOLOGY AND THERAPEUTICS. 

inflammation are, he thinks, the signs of "damage." A damaged 
blood-vessel is relaxed for the same reason that a damaged heart or 
a damaged intestine is relaxed. The penetration of the leucocytes 
through the vascular wall is due, he says, to the power possessed 
by these amoeboid bodies to introduce their own substance into 
that of dead tissue or into any material capable of imbibition with 
which they are brought in contact. These views are not at all in 
harmony with those held a generation ago, when inflammation was 
regarded as an increased nutrition of the part. This nutrition was 
supposed to be necessary to enable the tissues to repair the injury 
to which they had been subjected. Before the days of antiseptic 
surgery it was thought that a brisk inflammation was essential to 
seal the lips of a wound, but it is now known that union can take 
place with hardly a sign of inflammation. Repair need not, now- 
a-days, be looked upon as part of inflammation, but, as Sanderson 
says, as the result of the power of renewal in the adjacent unde- 
stroyed tissue. These facts are becoming more evident as year by 
year the surgeon becomes convinced of the difference between the 
old "traumatic inflammation" and the uncomplicated process of 
repair. 

Inflammation cannot, however, be regarded as simply an arrest 
of function. The apparatus of nutrition still continues to perform 
its duties so long as its vitality is maintained, although in an 
imperfect way. Moreover, we have to deal here not only with the 
nutrition, but with the protection, of the part affected. The new 
cells are present, not only for the purpose of repair, but also to 
ward off or to remove injurious particles and poisons. In attempt- 
ing, then, to describe the nature of inflammation it should, in the 
light of the latest discoveries, be defined as a lesion in the mechan- 
ism of nutrition, owing to which its efficiency is impaired, but which, 
if not so severe as to cause death, produces conditio7is favorable for 
the protection and repair of the part. 

The leakage of the vessels causes an increased formation of 
lymph, which flushes and washes out the morbid tissues, exerts an 
antiseptic action, and brings with it the protecting phagocytes and 
the materials suitable for repair. 

Inflammation has been likened to a conflagration which destroys 
without repairing ; but the forest fire, although it carries destruc- 
tion in its path, sweeps away also the pests that prey upon vege- 
table life, and leaves behind in the ashes materials and conditions 
suitable for a new growth of timber. 

Inflammations arise from manifold causes, but they have usu- 



SIMPLE INFLAMMATION. 121 

ally been classified into three separate categories : (i) trauma or 
mechanical injury; (2) chemical action, including usually heat 
and cold and drugs, and, by some authors, also the poison of 
insects and serpents ; and (3) infection, due to the action upon 
the tissues of micro-organisms known as bacteria. There are 
other agencies that cannot well be included under any of these 
heads, such as the action of the nerves, about which there has 
been much dispute, and the exclusion of blood from a part for 
a certain length of time. This, as has been pointed out, can be 
done experimentally by the application of a rubber ligature to 
the ear of the rabbit or to the tongue of the frog; but there 
are also clinical examples of it in the inflammation which pre- 
cedes a bed-sore or in that which follows the milder forms of 
frost-bite. The action of heat brings about distinct chemical 
changes in the tissues, and it should not therefore be associated 
with cold as a similar cause of inflammation, as is ordinarily done. 

Examples of inflammation due purely to trauma are seen in 
extensive contusions and simple fractures. In such cases bacterial 
action may, in the great majority of cases, be excluded, and yet in 
a simple fracture of the tibia, for instance, the symptoms of 
inflammation are seen well marked. The whole region from the 
ankle to the knee-joint is swollen, hot, and painful, and the limb 
is rendered useless. The color varies according to the amount of 
exudation and hemorrhage which occurs in the tissues. It is not, 
however, a brilliant red, such as is seen in infective inflamma- 
tions. Such inflammations do not have a tendency to spread. 

Examples of chemical action are furnished by drugs which may 
have a predilection for certain organs, where they will produce 
inflammation if used in poisonous doses. Thus, mercury will act 
upon the mouth, producing salivation, and cantharides upon the 
urinary organs; gouty inflammations may also be placed in this 
category. 

The group of purely toxic inflammations are most appropriately 
placed under the head of chemical action, for such is the nature of 
the poison of serpents and insects, so far as known at the present 
time. There are also chemical substances developed as the result 
of bacterial action, but these are incidental features of infection, 
and cannot be classed in the former category without much con- 
fusion. To this class of substances belong the ptomaines. The 
poisonous action of certain plants, such as ivy, is another example 
also of the group of chemical poisons. 

The action of bacteria in producing inflammation is now recog- 



122 SURGICAL PATHOLOGY AND THERAPEUTICS. 

nized everywhere. The relation of these micro-organisms to 
the inflammatory process will be considered in another chapter. 
The prominence which should be ascribed to them as causes of 
different kinds of inflammation is a question about which there has 
been, and is still, considerable difference of opinion. As progress 
is made in the minuter knowledge of the germ-theory of disease 
there is a tendency to relegate to the action of bacterial influence 
a larger and larger number of inflammations. Extremists, like 
Heuter, maintained that all inflammations were due to bacteria. 
Sanderson quotes him as follows: "Septic organisms exist every- 
where, ready, whenever access is offered to them, to enter the 
body and fulfil their morbific function. Consequently, inflamma- 
tion may be defined, with reference to the universality of its cause, 
as an epidemic and contagious disease which prevails universally 
over the whole world, with the exception of mountainous regions 
near and above the line of perpetual snow. Here there are no 
germs, and, we may presume, no possibility of inflammation." 

Heuter' s views were based upon the experiments of Zahn and 
others that subcutaneous tissue could be destroyed by the actual 
cautery or by chloride of zinc without causing inflammation. 
These experiments will be discussed elsewhere. 

It was well that Lister raised a warning voice against the 
tendency of the time, and at the Congress in London he undertook 
to show that the germ-theory of inflammation was carried too far, 
and illustrated his point by showing the influence which the 
nervous system has upon inflammation. If the nerves take no part 
in inflammation, of what use, he argues, is counter-irritation, such 
as the actual cautery in joint disease or the treatment of sore 
throat by the use of mustard? If this kind of treatment cures 
an inflammation by withdrawing nerve-action from the part, it 
follows that the disease was maintained by an abnormal action of 
the nerves. Catching cold is thus defined by Lister: u A diminu- 
tion of the action of the nerves of a part of the surface, leading 
to the increased action of the nerves of an internal organ in 
sympathy with that part." Van Buren, however, explains catch- 
ing cold by an arrest of function of the skin as an emunctory, 
whereby certain effects and presumably noxious materials which 
should be eliminated are retained and act as blood-poisons. This 
view of an auto-infection, which is gaining ground, has lately 
been brought forward to explain many febrile and inflammatory 
disturbances due to ptomaine absorptions arising from gastric and 
intestinal disorders. 



SIMPLE INFLAMMATION, 123 

The influence of the nerves has long 1 been recognized as an 
agent active both in the nutrition of the part and in producing 
inflammation. The theory of the trophic action of nerves was based 
largely upon the classical experiments on the vagus and trigeminus. 
After division of the ophthalmic branch of the fifth pair of nerves 
a necrosis of the cornea occurs within a short time, which con- 
dition eventually leads to destruction of the eye. The so-called 
11 vagus pneumonia" is an inflammation of the lungs following 
division of the nerve. But these experiments have been explained 
in other ways. The division of the trigeminus was found to 
interfere with the power of winking and with the secretion of 
tears, and the insensibility of the cornea permitted abrasions and 
ulcerations which opened the way for an invasion of bacteria. 
Careful protection of the eye by stitching the lids together 
prevented inflammations. Vagus pneumonia was found to be 
caused by anaesthesia of the larynx and paralysis of the oesopha- 
gus, which allowed the saliva and food to flow into the bronchial 
tubes. The so-called "schluck-pneumonie" of the Germans 
corresponds to this, and it is occasionally a sequel of severe opera- 
tions upon the tongue and throat. In such cases as this there is 
also an extensive infection of the lung with bacteria. 

Such explanations as the above have served to throw consid- 
erable doubt over the influence of the trophic nerves, or indeed as 
to their very existence, but Graefe has shown that if the trigeminus 
is left uninjured, but an equivalent of exposure of the eye is pro- 
duced by cutting away the lids and the lachrymal gland, there is 
not nearly so much inflammation as there is upon section of the 
nerve, and it is also of a different kind. Moreover, cases every 
now and then occur which are strongly suggestive of nerve-action. 
Of such was a case of left pleuro-pneumonia with herpes of the 
lower side of the chest. Vernet reports a case of acute right lobar 
pneumonia, with herpes of the palate, throat, and nose and over 
the right eighth intercostal nerve and the last phalanx of the 
middle finger of the right hand. Naso-labial herpes on the same 
side as the lung lesion has frequently been noticed. Herpes zoster 
is an example of a pustular eruption following the course of a 
nerve, and is accompanied with infiltration of leucocytes both 
around the terminal branches and the trunk of the nerve. 

A gentleman eighty years of age was exposed to the draught of an open 
window while riding in the cars — an unusual exertion for him to make. Two 
days later herpes zoster of the occipital region of the exposed side came on 
and ran a typical course. 



124 SURGICAL PATHOLOGY AXD THERAPEUTICS. 

Paget in his lectures has described examples of the effects which 
disturbance of the nervous force may produce on the nutrition of 

a part. Inflammation of the conjunctiva may be excited by stim- 
ulus of the retina. Impairment of the nutrition of the skin as a 
result of injury of the nerves is sometimes manifested by a peculiar 
glossy condition of the integument. The vaso-motor disturbance 
described by Mitchell, Morehouse, and Keen has already been 
studied in a previous chapter. Swelling and inflammation of the 
finger-joints have been observed after fracture of the internal 
condyle of the humerus, causing an irritation to the ulnar nerve, 
and they have also been observed after Colles's fracture. 

The condition of the bladder after the destruction of the spinal 
cord has long been ascribed to removal of the protective influence 
of innervation. Many of the cases of urethral fever which were 
supposed to be typical examples of reflex inflammation are now 
well known to be due to bacterial infection, but a certain number 
of them are difficult to account for in this way. 

A man of middle age, with secondary syphilis and a stricture of large 
calibre of the pendulous urethra and two perineal fistulas, entered the Massa- 
chusetts General Hospital for treatment. The first day an attempt was 
made to pass a polished steel sound of about No. 12 calibre, but. although the 
stricture did not yield, not enough force was used to draw blood, and the 
attempt, which was quite painful, was abandoned. On the second day there 
was high fever with suppression of the urine, and death occurred on the 
third day. At the autopsy the kidneys were found deeply congested and an 
acute nephritis existed. 

Norton defines urethral fever as " a reflex paralysis, or, in other 
words, an exciting impression upon or injury to a set of peripheral 
nerves which by reflection through a centre may result in paralysis 
of the whole or a part of the united cerebro-spinal and sympathetic- 
nervous system, .... bringing about structural changes or sup- 
puration in organs or other tissues. 11 

Norton reports a case of sounding for stone in oxaluria. after which there 
were fever, rigors, partial right hemiplegia, and ptosis of the left side, and 
hypersemia of the left side of the neck and face. Five weeks later an effusion 
into the left tunica vaginalis occurred. In a second case — one of stricture — 
catheterism produced high fever, later suppression of urine, and later still 
herpes of the face and neck. The writer assumes an "arterial fluxion" of 
the testis and kidney in these cases. 

Suppuration, Norton thinks, may occur in these organs, and 
abscesses in distant parts may even occur, solely from reflex 
irritation. 



SIMPLE INFLAMMATION. 125 

Horner describes nervous swellings, of considerable dimension, of the 
skin accompanying- menstruation and the menopause. These swellings were 
seen about the face and the lips, and also in other parts of the body, and they 
consisted of an active hyperaemia and also of a considerable exudation of 
lymph — a condition closely allied to inflammation. 

Although the writer is not prepared to follow these observers to 
the full extent of their theories, yet it must be acknowledged, from 
the large mass of accumulated information showing such a close 
relation between nerve-action and inflammation, that it seems 
reasonable to assume that the old views are not entirely without 
foundation. It may be, in some cases, that the innervation of the 
part is so affected that bacterial invasion can take place, which 
would have been successfully resisted by the tissues in health. 

Foreign bodies produce suppuration by means of bacterial 
action. They may undergo decomposition, or, if composed of a 
substance not capable of decomposition, they may excite a local 
irritation which favors bacterial infection of the surrounding parts. 

Among the predisposing causes of inflammation may be men- 
tioned that of age. Disturbances of nutrition in growing children 
lead readily to inflammations which are not likely to occur in the 
adult, such as affections of the mucous membranes and of the bones. 
In old age the power of resistance to invading organisms is less 
marked, and many catarrhal affections are seen at this period. 
Morbid conditions of the blood (such as gout, scurvy, diabetes 
mellitus) subject the patient to inflammations of the joints, of the 
mucous membranes, and of the skin. The influence of climate is 
also a potent factor both in wintry and in changeable climates, 
like that of New England, where affections of the throat and of the 
oesophagus, and, in more equable and tropical countries, where the 
abdominal viscera are more liable to inflammations. The habits 
and customs, and even the costumes, of nations are affected by 
these influences ; the scarf or muffler of the Northerner is replaced 
by the belt and sash of the inhabitants of the East. 

3. Varieties and Treatment of Inflammation. 

Formerly it was customary to divide inflammations into two 
general varieties — idiopathic and traumatic. The latter variety 
included those inflammations arising from injury of whatever 
kind; the former variety embraced those inflammations which 
were supposed to arise spontaneously. Little was known about 
the etiology of inflammation at the time this classification was 
made, but as the knowledge of pathological processes has in- 



126 SURGICAL PATHOLOGY AXD THERAPEUTICS. 

creased less is heard of idiopathic inflammations, the term being 
now rarely used, and only in a limited sense to indicate inflamma- 
tions that are not traumatic. The form of inflammation to which 
the present studies have hitherto been confined is the simple 
inflammation — that is, the non-infective form of inflammation. 
The causes of such an inflammation, as has just been seen, may 
be various, but there are no complications such as would be 
accounted for by the presence of bacteria. Burdon Sanderson 
says of it: "An uncomplicated inflammation is neither reproduc- 
tive nor infectious, neither benign nor malignant. It has no 
tendency except the tendency to leave off as the occasion for it 
ceases." Infective inflammations are those due to the presence of 
bacteria, and they are in marked contrast to the form just men- 
tioned. They are destructive in their nature, and through the 
action of those organisms the inflammation spreads progress: 
until whole organs are destroved. 

The division of inflammation into sthenic and asthenic is based 
upon the condition of the soil in which the disease occurs, rather 
than upon the nature of the process itself A sthenic inflammation 
is rue in which all the phenomena are present and well marked in 
character, such as is likely to occur in previously healthy tissues 
and in a powerful and vigorous subject. The color of the inflamed 
focus is a brilliant scarlet, the swelling is pronounced, and the part 
is hot and highly sensitive to the touch. The disease runs an 
acute course, whatever may be its termination. 

Asthenic inflammations occur in old or in feeble individuals, 
and are marked by symptoms so slight as frequently to be over- 
looked. They play a conspicuous part in many of the complica- 
tions which attend disease and injuries in the aged. Hypostatic 
inflammations, which are familiar to the surgeon as the result of 
a feeble circulation, occur in dependent portions of the body dur- 
ing prolonged confinement to the bed. Such is the occurrence also 
in old people of pneumonia during convalescence from an injury 
or an operation. A very slight cause may in these zases be sufficient 
to give rise to a condition which may become more grave than the 
original lesion. The terms "sthenic" and "asthenic," however, 
are rarely used. 

An anatomical division of inflammations may be made if we 
choose, with Virchow, to classify them according to the seat of the 
es attacked. 

According to this view, parenchymatous inflammations are 
attended by the changes seen in the cells peculiar to a given organ, 



SIMPLE TNFL. I MM. I TION. 1 27 

which cells become cloudy from granules deposited in their pro- 
toplasm, and subsequently undergo degenerative changes, and, if 
on the surface, they are thrown off by a process of desquamation. 
These changes are, however, at the present time regarded as degen- 
erative from the beginning, as the term "parenchymatous" is no 
longer considered as representing a special type of inflammation. 

Interstitial inflammations involve the parts around the blood- 
vessels, and consequently they occupy the connective tissue form- 
ing the stroma of organs. They are usually chronic in course, and 
are attended with the formation of cicatricial tissue, which con- 
tracts and is attended with a gradual diminution in the size of the 
organ — a condition known as cirrhosis. 

Inflammations can be divided into various classes according 
to the prominence of certain pathological conditions. In some 
cases it is found that there is an unusually small number of white 
corpuscles in the serum, and this fluid may contain less albumin 
than usual. This form is called "serous" inflammation, a familiar 
example being the abundant effusion sometimes attending a mild 
form of inflammation of the knee-joint. Many of these so-called 
''dropsies" of the joints are undoubtedly the result, simply, of an 
altered function of the endothelial cells lining the synovial mem- 
brane, but others are the outcome also of a genuine pathological 
condition, such as an inflammation following injury or some con- 
stitutional condition, as rheumatism. The abundant collections 
of fluid deposited in loose tissues in the neighborhood of acute 
inflammations, as in the eyelids or in the prepuce, are of the same 
serous character, and are the result of pressure which has forced 
the serum in the direction of least resistance. The fluid will in 
this case be thin and watery, having already been deprived of its 
fibrinogen while in contact with the leucocvtes. These collec- 
tions of serum may in some cases become an element of danger, 
as in extensive inflammatory swellings of the neck, where there 
may be pressure upon the laryngeal nerves or an oedema of the 
larynx which may seriously obstruct respiration. The amount of 
serum — or, more correctly, of liquor sanguinis — which exudes 
from the vessels when the surface of the wound has been irritated 
is much greater than one might suppose. These collections of 
fluid may become a great obstacle to the process of repair by for- 
cing apart the lips of a wound, and it has been the object of no 
small amount of study on the part of surgeons to devise some 
means to provide for this excess of exudation. 

When a large number of leucocytes are present, and when, 



128 SURGICAL PATHOLOGY AND THERAPEUTICS. 

owing to the severity of the inflammation, there is considerable 
disintegration of these corpuscles, possibly the result of a struggle 
with certain forms of bacteria, coagulation of fibrin takes place, 
and the exudation, if it be liberated into the interstices of areolar 
tissue, solidifies. If the exudation takes place upon a mucous sur- 
face, a pseudo-membrane is formed by the fibres of fibrin inter- 
lacing with one another and enclosing leucocytes in their meshes. 
Such fibrinous forms of inflammation may be the starting-point of 
organized tissue, and later blood-vessels may shoot out into these 
membranes, new tissue being thus developed. In this way two 
opposing surfaces, as in the peritoneal cavity, may be glued to- 
gether, and the new-formed tissue is known as an adhesion. Here, 
again, the protective influence shows itself, for in this way per- 
forations of the intestinal canal may be closed and the peritoneal 
cavity may be shut off from an invasion of bacteria, which abound 
in intestinal secretions. Certain serous membranes are particularly 
prone to such adhesive forms of inflammation, and the adhesions 
which form may impair the motions of the opposing surface, as in 
the pleural cavity or in joints, and may thus constitute a more or 
less serious complication. It is due to the adhesive nature of 
lymph that the edges of a wound are quickly sealed together. 
This complication rarely occurs in mucous membranes ; for the 
epithelium, so long as it is preserved, prevents the formation of 
fibrin, and there takes place a serous discharge holding more or 
less leucocytes and some epithelium in suspension, and constituting 
the condition known as catarrh. In severer varieties of inflamma- 
tion coagulation of the fibrin takes place, and a membrane is 
formed upon the surface which is known as croupous. There is no 
tendency to organization nor to the formation of adhesions in 
these cases, for the presence of bacteria brings on a discharge of a 
mucous or purulent character which sweeps away the membrane 
thus formed. A diphtheritic membrane is formed by a hyaline 
transformation or coagulation-necrosis of the tissues composing the 
mucous surface itself. 

This change in the tissues is due to the presence of bacteria, 
and it is probable that the tendency of the fluids of the tissues to 
coagulate, and the tissues themselves to be transformed into a more 
or less homogeneous material, is due to the action of some sub- 
stance liberated by these organisms during their development and 
growth. Such a mass of dead tissue — which if it occurred in a 
wound would be called a " slough " — can only be separated from 
the living tissues by a process of liquefaction, this change being 



SIMPLE INFLAMMATION. 129 

effected through the medium of suppuration. When pus is 
formed, the fibrin cannot coagulate, or, if already coagulated it 
will subsequently be dissolved, owing to the presence of a 
chemical substance known as peptone, or some substance formed 
bv the bacteria of suppuration having a solvent action. 

When suppuration takes place the croupous or the diphtheritic 
membranes are separated and are carried off, and in their place is 
found a formation of pus covering an ulcerated surface, which by 
subsequent cicatrization may heal and return to a normal con- 
dition. Pus may, however, be discharged from an inflamed 
mucous membrane whose epithelium has not been destroyed. 
Such is the nature of the gonorrhceal discharge, consisting of 
plasma filled with innumerable leucocytes, forming a creamy fluid 
in which there is no tendency to coagulation owing to the pres- 
ence of the gonococcus. 

Hemorrhagic inflammations may be mentioned again in this 
place, merely to state that they are due to a high grade of inflam- 
mation resulting in an intense congestion and stasis in the cap- 
illaries. Red corpuscles are thus forced out by pressure. But the 
same conditions may be brought about by weakness of the vessel- 
wall as the result of a hemorrhagic diathesis or in connection with 
new formations where the tissues have a feeble organization, as in 
cancer. The existence of blood in the exuded serum or lymph is 
characteristic of certain affections. In the hernial sac a bloody 
serum accompanies strangulation of the bowel, being partly due to 
passive hyperaemia and partly as the result of an inflammatory 
congestion of the peritoneum. The aspiration of bloody fluid 
from the pleural cavity is a symptom strongly suggestive of the 
existence of malignant or tubercular disease. 

Inflammation may terminate either in resolution, in death of the 
part, or in suppuration. A termination by resolution means that 
the various symptoms gradually subside and disappear and the 
part returns to its normal condition. When the inflammatory 
agent ceases to act, the distention of the vessels begins to subside 
and the flow of blood to resume its natural course. The heat 
and increased redness therefore begin to disappear from the part. 
The rapidity with which the swelling goes down depends upon the 
amount and the character of the exudation which has taken place. 
If this exudation has been largely serous, containing but few 
corpuscles, the lymphatics will be able to take it up speedily and 
effectually. If, however, a larger number of leucocytes are 
present, it will not be possible for the lymph-channels to provide 



130 SURGICAL PATHOLOGY AND THERAPEUTICS. 

rapid absorption from the inflamed area. Some of these cells are 
taken up by the lymphatics and carried back into the circulation; 
some undergo degenerative changes; others have already broken 
down during the progress of the inflammation, and their substance 
appropriated by larger cells, the ' ' macrophagocy tes. ' ' In this 
way the debris of the inflammatory process is swept away. 

If, however, the exudation goes on to such an extent that the 
part is completely infiltrated with leucocytes, the structure of the 
tissue itself will seriously be impaired, for, as the leucocytes accu- 
mulate in large numbers, the fibres and the cells of the part dis- 
appear. The' fixed cells undergo proliferation and become indis- 
tinguishable from the migratory cells, and the intercellular sub- 
stance is gradually changed into a more or less homogeneous 
granular material in which the new cells are imbedded. The 
tissue thus formed, which is a temporary tissue of an embryonic 
character, replaces more or less completely the normal tissue of 
the part, and constitutes what is termed granulation tissue. 
Under these circumstances not only must absorption of the new 
cells take place, but a considerable reparative change must occur 
before the parts can return to their original condition. An inflam- 
mation which terminates by resolution is usually of a milder 
type. 

In some forms of inflammation all the symptoms may be much 
severer, particularly the swelling. This swelling may occur to 
such an extent as seriously to impede the flow of blood to the part, 
and stasis or a stoppage of the flow of blood through the muscles 
will take place. Should this swelling be limited only to a small 
area, such as is supplied by a few capillary vessels, probably no 
permanent ill effects would follow, but more extensive obstruction 
to the blood-flow would undoubtedly lead to death of the part. 
Such complications, fortunately, are rare, but they are sometimes 
seen following inflammation of the mouth in children, and they 
involve a slough of an extensive portion of the cheek, as in noma. 
They are, however, usually secondary to other diseases, and 
belong chiefly to the class of infective inflammations. When 
mortification of a considerable portion of a limb follows a trau- 
matic inflammation, it is generally found that some complication 
has occurred, such as the rupture of an artery. Another and more 
frequent termination of inflammation is suppuration, but this 
branch of the subject will be considered in another chapter. 

In studying the treatment of inflammation it is well to consider 
whether there are any therapeutic means which, in the light of the 



SIMPLE INFLAMMATION. 131 

present studies, will enable the surgeon to produce an effect upon 
the local processes. 

In former times the belief was strong that such an effect could 
be produced, and for this purpose all the measures which belonged 
to what was then known as the antiphlogistic treatment were 
brought to bear. These measures consisted not only in local 
remedies, but also in such remedies as powerfully affected the 
whole system. Venesection was not infrequently accompanied by 
an emetic. It was thought that by abstracting blood and thus 
weakening the heart's action less blood would be carried to the 
part and the violence of the process would be subdued. Leeches, 
blisters, heat, and cold were alternately applied to the part with 
the view of directly combating the processes themselves, without 
taking into account the causes which produced them. The exu- 
dation, it is true, was supposed to be due to a fibrinous crasis, and 
mercury was also freely used to exert a solvent action upon the 
coagulated lymph, thus favoring absorption. 

The antiphlogistic has now given way to the antiseptic treat- 
ment ; that is, therapeutic measures are now directed rather 
against the causes than the result of inflammation. The treat- 
ment of to-day is mainly directed to prevention of inflammation, 
and how far this attempt has succeeded few are able to realize who 
are unfamiliar with the appearance of hospital wards before the 
antiseptic era. Still, inflammation is always present in a more or 
less aggravated form, and appropriate remedies are as much in 
demand as ever. Attempts have been made to determine whether 
an intimate knowledge of the processes of inflammation enables 
one to combat them scientifically. The treatment of the septic 
forms of inflammation or those due to bacteria will be discussed in 
another place. The point more especially of interest now is to 
determine the degree of influence which remedies will exert upon 
the processes themselves. Nancrede, who has studied this question 
experimentally, points out that in inflammation the excess of 
plasma cannot be carried off by the lymphatics, as they are com- 
pressed by the swelling of the parts and are blocked with leu- 
cocytes. The vessels are distended, and the existing intravascular 
pressure favors an excess of exudation, which is aggravated also 
by the presence of unusual numbers of red corpuscles that bring 
an excess of oxygen to the part, thus exciting the leucocytes to 
increased amoeboid action and to their consequent migration. 

A theoretically-perfect remedy should therefore relieve pressure 
from the heart's action, thus preventing over-distention of the 



132 SURGICAL PATHOLOGY AND THERAPEUTICS. 

already distended blood-vessel's walls. It must prevent also such 
ingress of blood as to cause an excess of oxygen with the increased 
exudation that results, and it must favor the escape of blood on 
the venous side, so as to drain off the stagnant blood. The heart's 
action, though diminished in force, should be increased in frequency 
to favor a return to active circulation. 

Nancrede divided a large vein on the distal side of the circulation 
in the inflamed tongue of a frog. ' ' The effect, ' ' he says, ' ' upon 
the obstructed vessels was first an oscillation of the blood-disks, 
then an occasional momentary flow of blood, then suddenly a rapid 
resumption of the circulation, sweeping out the blood-vessels and 
apparently restoring them to their normal condition, except at spots 
where the agents inducing the inflammation had chemically 
destroyed the vessels or coagulated their contents." 

Gensmer produced a more decided effect upon the circulation in 
the web of a frog's foot by applying a leech to the hock-joint. 
General bloodletting by opening an abdominal vein was inferior to 
leeching near the affected area. Local bleeding, Gensmer thinks, 
relieves stasis and causes a more abundant supply of arterial blood 
to the part, thus better nourishing the tissues, and enabling them 
to withstand the effect of the inflammatory process. He says the 
water is increased and the oxygen-carriers are diminished in the 
blood-vessels of the part ; the action of the heart becomes more 
rapid and its force lessens. Here, then, is secured the desired 
effect upon the circulation. 

Arterial sedatives were not found to have the same effect upon 
the circulation. Experiments show that, in giving gelsemium, 
the arteries become smaller, that the current is slower, and that 
stagnation is increased. Nancrede concludes that during the stage 
of active hypersemia little danger exists of changes in the walls of 
the capillaries and of exudation. At this stage ergot or arterial sed- 
atives would act favorably by reducing the size and rapidity of the 
current, thus allowing the veins of the irritated area to empty 
themselves, and giving the circulation an opportunity to return to 
its normal condition. 

After the stage of capillary stasis is reached arterial sedatives 
can only do harm, and blood should now be removed from the 
venous side of the circulation. The best results are obtained by 
bleeding from one of the principal veins leading from the inflamed 
focus. When bleeding is impossible leeching or wet cups should 
be resorted to. In this way the vessels are not only emptied, 
lessening the pressure, but an aspiration is also invoked which 



SIMPLE INFLAMMATION. 133 

increases the rapidity of the flow, and this flow, as it is unaccom- 
panied by increased pressure, sweeps away the leucocytes and 
removes the excess of oxygen, and thus lessens migration ; it also 
helps absorption of the exposed lymph. This absorption occurs a 
few hours after the leeching, as shown in the wrinkling of the skin 
seen about that time. 

In the later stages of inflammation arterial sedatives act favor- 
ably after bloodletting, because they lessen intravascular pressure, 
thus permitting the vessels to recover their normal condition. By 
lessening the bulk of blood in the part sedatives relieve nerve- 
pressure and, consequently, pain. Independently of bloodletting, 
they would act favorably only on the surrounding congestion, and 
would not help the conditions obtaining in the inflamed focus itself. 

Such studies as these, which have more than a theoretical value, 
should be encouraged, for they are of great service in helping one 
to obtain an intelligent idea of how to attempt to control the cir- 
culation in deep-seated inflammation, particularly in the brain, 
where slight changes in the current of blood within the vessels or 
of exudation into the delicate tissues surrounding them are pro- 
ductive of grave results. 

As local applications to inflamed parts both heat and cold act 
favorably by the action they produce upon the blood-vessels. The 
ice-bag can be applied in those cases in which congestion of ves- 
sels is a prominent feature, and where redness and heat are con- 
sequently pronounced symptoms. The soothing action of cold 
always makes it a welcome application. If, however, the swelling 
is great, the circulation is sluggish, the color is dusky, and the 
temperature of the parts is low, cold would tend to aggravate 
rather than relieve the symptoms. 

Heat acts differently according to the degree used. Warm 
poultices favor an increase of hyperemia and consequent flushing 
of the part. The exudation may thus be increased until pus forms, 
or the flushing of the part with blood-serum may bring about an 
antiseptic action, and thus prevent suppuration. Heat will in this 
way favor the absorption of the exudation, and it will in any case 
have a soothing influence upon the nerves of the part. Greater 
heat will constrict the blood-vessels. Thus very hot poultices, fre- 
quently applied, will sometimes check an incipient inflammation, 
and in chronic congestion of the cervix uteri the hot doiiche exerts 
its curative influence by this action upon the vessels. 

The influence of counter-irritation has already been alluded to. 
Counter-irritation can be applied either in the shape of the actual 



134 SURGICAL PATHOLOGY AXD THERAPEUTICS. 

cautery or the blister or in milder ways. It alters in some way 
the nerve-action of the part, and thus controls the circulation. It 
exerts its influence partly by reflex nerve-action and partly upon 
the local vaso-motor apparatus. It also stimulates absorption. 
Internally opium may be given to relieve pain and to ensure rest 
to the part. As a rule, depletive measures should be avoided, and 
the strength of the patient should be maintained by careful atten- 
tion to his diet and to his surroundings. 



VI. INFECTIVE INFLAMMATION. 

i. Etiology. 

Thus far, attention has chiefly been called to the simple forms 
of inflammation. The form that will next be studied has the 
peculiar characteristic that its tendency is not, like that of simple 
inflammation, to remain local and to subside, but rather is to spread 
and involve surrounding parts. This peculiarity, which re7iders it 
a much more formidable type of disease, is due to the presence of 
bacteria. The surgical affections caused by these organisms may 
be considered as complications attacking the healing of wounds, 
and constitute that group of affections known as the traumatic 
infective diseases. 

Infective inflammation terminates, in the great majority of cases, 
in suppuration, and the forms of bacteria now recognized as the 
cause of pus-formation are known as the pyogenic cocci. Infective 
inflammation differs, therefore, from simple inflammation in its 
bacterial origin and in the destruction of tissue which it involves. 
The old view of suppurative inflammation, as described by Billroth 
and elaborated by Cohnheim, was that it consisted in an enormous 
multiplication of the cells of the part due to diapedesis of leuco- 
cytes, and that the fluid portion of the exudation failed to coagu- 
late, and that this, with a softening of the intercellular substance, 
produced liquefaction of the tissues, thus forming pus. Why the 
fibrinogen did not coagulate was not precisely understood, but it is 
now known that fibrinogen is changed by the bacteria into peptone. 
This peptonizing action of the pyogenic cocci is one of their most 
marked peculiarities, and the fermentation which occurs in the 
products of suppurative inflammation is thus adequately explained. 

The frequency with which these organisms are found in the 
human subject is pointed out by Ogston, who examined the pus 
from one hundred abscesses. Cocci were found in all acute ab- 
cesses, and were absent in all cold abscesses. The experience of 
subsequent observers has practically been the same. The only 
points about which there is at present any question are the etiology 
of the cold abscess and the relative frequency with which the dif- 
ferent types of pyogenic cocci are found in the different clinical 

135 



136 SURGICAL PATHOLOGY AND THERAPEUTICS. 

varieties of acute suppuration. It was at one time supposed that 
the cold abscess was caused by the bacillus of tubercle only, but 
this view has not fully been sustained. In a large number of cases 
it is not possible to demonstrate their presence either in the con- 
tents or in the walls of an abscess. The absence of pyogenic cocci, 
as shown by the failure to obtain a culture from the pus of a cold 
abscess, is explained by the dying out, owing to their age, of the 
organisms concerned in the abscess. This explanation does not 
seem to be altogether satisfactory, inasmuch as the cultures of these 
organisms show that they can retain their vitality for a very great 
length of time. It is possible that cocci may settle and form a 
deposit at the bottom of an abscess, the other portion of the pus 
beino; sterile. (Vston has demonstrated that the numbers of cocci 
greatly vary according to the activity of the suppuration. In acute 
abscesses he found an average of 917,775 cocci to 1 c.mm. of pus, 
and in the more chronic forms of abscess there were only 395,500 
cocci. The fact is, that cocci are found in many of the abscesses 
originally starting from tuberculosis of the bone. H. C. Ernst dem- 
onstrated the presence of the aureus, albus, and tenuis in several 
cases of psoas abscess. Rosenbach obtained general tuberculosis 
in animals by injecting pus from cold abscesses, and the cultures 
taken from the same pus proved sterile. 

The types of disease in which pyogenic cocci are found are 
acute localized abscesses of all kinds, such as boils, carbuncles, 
suppurating glands, empyema, abscesses of the parotid, mamma, 
and tonsil, synovitis, and osteomyelitis. In these forms the 
staphylococcus group is usually found. The streptococci are more 
frequently seen in the spreading inflammations, such as phlegmon- 
ous cellulitis and phelgmonous erysipelas. 

Experiments on animals have abundantly proved that cultures 
of these organisms when injected into their tissues would produce 
suppuration. One or two examples it may be well to give. 

Knapp tested the action of sterilized foreign bodies when introduced 
into the cornea, and found that suppuration did not take place, but when the 
object was previously dipped in a pure staphylococcus culture suppurative 
keratitis always occurred. H. C. Ernst injected into a guinea-pig the staphy- 
lococcus pyogenes aureus from a perinephritic abscess which occurred in a 
patient in the writer's hospital service, the patient subsequently dying of 
pyaemia. The seventeenth generation was used for the purpose, the culture 
process lasting over a year. There was developed in the guinea-pig an 
abscess full of thin yellow pus, cultivations from which showed the presence 
of the staphylococcus aureus. 

It has been proved, however, that under certain circumstances 



INFECTIVE INFLAMMATION. 137 

injections of the pyogenic bacteria will not produce suppuration. 
The experiments of Gram on the peritoneal cavity of animals has 
a bearing upon this point. He found that a considerable number 
of bacteria could be introduced into the peritoneal cavity without 
affecting the health of the animal. He concludes that in order to 
act the pyogenic cocci must have certain conditions of the tissues 
pre-existing that germination may take place. So long as the 
surface of the peritoneum remains uninjured, millions of bacteria 
may be absorbed, but if fluid containing them is injected in such 
quantity that it cannot be absorbed readily, or if the peritoneum is 
injured, peritonitis will occur. 

Rapidity of absorption will equally well save other parts of the 
body from the ravages of the pus cocci. This has repeatedly been 
proved to be the case after the injection of pure cultures into the 
subcutaneous tissue of animals when the point of injection has 
been touched by the actual cautery. The heat acted as a stimu- 
lant to the absorbents, and the injection was followed by a 
negative result. 

Watson Cheyne has shown that the number of bacteria injected 
makes a very great difference in the result. He obtained by plate- 
culture a general idea of the numbers existing in a given quantity 
of a fluid, the fluid being diluted for the purpose: a certain amount 
of this material was injected into an animal, and at the same time 
plates were made from a similar quantity. He thus ascertained 
quite accurately how many organisms were present in the fluid 
injected. In the case of the proteus vulgaris he found that fa cc. 
of an undiluted cultivation, an amount containing 250,000,000 
bacteria, injected into the muscular tissue of a rabbit, proved to be 
a rapidly fatal dose: fa cc, containing 56,000,000 bacteria, caused 
an extensive abscess, from which the animal died in six to eight 
weeks. Doses of less than 18,000,000 bacteria seldom caused any 
result. In the case of the staphylococcus pyogenes aureus he 
showed that it was necessary to inject something like 1,000,000,000 
cocci into the muscles of a rabbit to cause a rapidly fatal result, 
while 250,000,000 produced a small circumscribed abscess. The 
albus in smaller doses was found to produce the same result. He 
proved further that the concentration of the bacterial material was 
of great importance, as shown by the fact that the dose must act 
at the same place and at the same time. Splitting up the dose 
and injecting various portions of it into different parts of the 
animal at successive periods of time or at the same time did 
not produce the same result. He found also that the dose for 



138 SURGICAL PATHOLOGY AND THERAPEUTICS. 

different animals varied according to the susceptibility of the 
animal. 

As a human being is not very susceptible to pyogenic organ- 
isms, the results produced by them in man vary according to the 
amount introduced. Consequently, a few cocci entering a wound 
would possibly do no harm unless, indeed, they met with con- 
ditions particularly favorable for their growth, such as the reten- 
tion of fluid or a clot in which they could readily develop and 
multiply. This probably accounts for the fairly good results 
obtained with imperfect aseptic work, the introduction of large 
doses of bacteria being thus avoided. The pyogenic cocci in 
small numbers are more liable to cause suppuration if accom- 
panied by a sufficient amount of toxic substances which are 
present in virulent cultures of the cocci, and the extent of the 
inflammation bears a relation to the quality and quantity of these 
substances. In infected cases these chemical products may be 
found in a much more virulent form than those products obtained 
from cultures, coming as they do from various sources and grow- 
ing under varying conditions. The presence in the circulating 
blood of the toxic products of some micro-organisms favors the 
development of foci of suppuration, as in pyaemia (Welch). 

Before, however, further discussing the questions of the con- 
ditions favorable for the growth and spread of the pus-cocci in the 
living tissues let us consider some of the experiments which prove 
the pyogenic action of these cocci upon man. Quite a number of 
such experiments have been made, and some of the most instruc- 
tive were those performed by Garre, who inoculated with a cul- 
ture of the aureus a fold of the skin at the edge of his finger-nail, 
and produced the typical suppuration round the margin of the 
nail commonly called a vl run-around. '' He next rubbed a large 
quantity of an aureus culture into the uninjured skin of his left 
forearm. A burning sensation began at the point six hours later; 
pustules appeared the following day; the inflammation continued 
to increase around the pustules, and the fourth day a carbuncle 
had developed: ultimately there formed more than twenty open- 
ings discharging pus and portions of dead tissue. From the pus- 
discharges a pure culture of the aureus was obtained. This 
experiment shows not only that the cocci were the cause of the 
suppuration, but also that they can obtain an entrance through 
the uninjured skin. It is evident that they must have penetrated 
through the glandular openings and hair-follicles. 

How this process is developed is shown in the experiment of 



INFECTIVE INFLAMMATIi 139 

Bockhart, who nibbed a culture of the aureus into his arm after 
scraping away the epidermis in one or two places. Pustules and 
isolated furuncles were developed. A piece of the diseased parts 

s excised and examined under the microscope. The cocci had 
grown in between the cells of the exposed rete Malpighii, thence 
into the papillae, and also into the hair-follicles and ducts of the 
sebaceous and sudoriparous glands. There was an active dia- 
pedesis of leucocytes from the vessels of the papillae surrounding 
the colonies of micrococci, and pustules were thus formed. Bock- 
hart concluded that if the pustule connected with a hair-follicle 
or a gland-duct, a boil would be produced; otherwise nothing 
more than a pustule would be produced. Similar results were also 
obtained by Wigglesworth. 

Bumm injected subcutaneously into his own arm and into the 
arms of several other individuals a few drops of a salt solution 
containing fragments of an aureus culture : abscesses varying in 
size from an egg to that of a fist were thus produced. In one case, 
when the abscess had not yet fully ripened, he excised the inflamed 
nodule, together with the surrounding skin and subcutaneous 
tissue. On section the specimen showed a yellowish, softened 
centre surrounded by a reddish zone, which gradually was replaced 
by normal tissue. Under the microscope the centre was seen filled 
with pus-cells on the point of breaking down into pus, and between 
the pus-cells were clusters of cocci. On the periphery of the sup- 
purating portion the cocci were seen in large clusters and in columns 
growing between the wavy fibres of connective tissue, followed by 
an enormous infiltration of leucocytes. Schiramelbusch, who 
rubbed a culture of the aureus into the skin of moribund patients 
and examined the pustules and abscesses thus formed, found that 
the infection took place through the hair-follicles between the hair 
and its sheath. 

The relative frequency with which the different varieties are 
found in cases of suppuration in man is shown by an analysis by 
Steinhaus of 330 cases of different observers. The staphylococci 

e found in 66.5 per cent, and the streptococci were found in 
20.4 per cent, of the cases, and a mixture of the two forms in 9.5 
per cent. The tenuis was found only in 1 per cent., and the other 
forms also quite rarely. 

The question now naturally arises : Is all suppuration in the 
human subject due to the presence of bacteria ? When Lister first 
showed that the suppuration of wounds was due to their presence 
by the very convincing argument of antiseptic surgery, the belief 



14-0 SURGICAL PATHOLOGY AND THERAPEUTICS. 

became almost universal that bacteria of some sort are always found 
as the active agents of suppurations. Previous to that time it had 
been supposed that mechanical as well as chemical irritation, and 
also foreign bodies imbedded in the tissues, could produce suppu- 
ration. But when the germ-theory had taken a firm hold a school 
was soon developed, at the head of which was Heuter, whose motto 
was : "No pus without bacteria." There were many, however, who 
were not prepared to allow such complete sway to micro-organisms. 
Billroth held the view that bacteria were not the cause, but were 
the accompaniment, of suppuration, and that a chemical substance, 
the "phlogistic zymoid " (a sort of chemical ferment), was the 
principal agent. Apparently in confirmation of this view there 
appeared in 1878 a report from Pasteur that he had been able to 
obtain suppuration with pus in which all the bacteria had been 
destroyed by heat of from ioo° to no° C. : in other words, from a 
fluid which contained only the chemical products of those organ- 
isms. As the knowledge of the pyogenic cocci became more 
accurate the disposition was strengthened to regard all suppuration 
as of bacterial origin. 

For the purpose of subjecting this theory to the most rigorous 
test a large number of investigations were made to determine 
whether it was possible to cause suppuration purely by chemical 
substances, such as croton oil, mercury, turpentine, etc. The early 
experiments of this kind were very contradictory, the errors of 
many observers being due partly to imperfect asepsis, and partly to 
the fact that in certain animals suppuration could be produced by 
those agents that entirely failed when other kinds of animals were 
used for the experiment. Since then, however, experience has 
shown the common sources of error, and some of the work has 
been so carefully performed that it seems impossible to be skeptical 
of the results obtained. 

Councilman was the first to show that croton oil could produce 
suppuration without bacterial action when injected into the sub- 
cutaneous cellular tissue of rabbits. Petrone succeeded in 1885 in 
obtaining suppuration in rabbits and in guinea-pigs with injec- 
tions of sterilized pus, thus confirming the experiments of Pasteur. 
Grawitz and de Bary found that turpentine caused suppuration in 
dogs, but not in rabbits nor in guinea-pigs. Ammonia, well dilu- 
ted, if injected into dogs, is absorbed, but in concentrated solu- 
tions it causes the formation of pus which -proves absolutely sterile 
to all culture-tests. Cultures of the micrococcus prodigiosus, 
sterilized by heat and injected, produced sterile pus in dogs, 



INFECTIVE INFLAMMATION. 141 

rabbits, and rats. The addition of a small quantity of an aureus 
culture to this material produced pus very rich in cocci. These 
authors concluded, as the result of their investigations, that certain 
chemical substances in certain strengths and injected into certain 
animals caused suppuration without bacteria, and also that these 
chemical substances pave the way for the action of bacteria. 

Interesting in this connection is the work of Leber, who suc- 
ceeded in obtaining from cultures of the aureus a crystalline sub- 
stance to which he gives the name u phlogosin." He has made a 
number of experiments upon animals with this substance, and he 
propounds a new theory of inflammation founded on the capacity 
which, as shown by botanists, is possessed by certain chemical sub- 
stances of attracting or of repelling certain kinds of organisms. 
Leber ascribes to phlogosin a similar chemotactic action upon the 
leucocytes, in virtue of which it draws them toward itself. The 
leucocytes, he thinks, play a double role : they absorb the irritating 
substances and dissolve or digest the necrosed portions of the 
inflamed tissues. Christmas showed clearly that the conflicting 
results produced by different observers were due to the varying 
type of animal used for experimentations. Turpentine and mer- 
cury failed with him to produce suppuration in rabbits, but caused 
suppuration in dogs. He explained this by the slower absorptive 
power which exists in the latter animals. He obtained suppuration 
in dogs with bouillon-culture of the aureus, not only after boiling, 
but also after filtering, the culture. His definition of suppuration 
is as follows : " Suppuration should be regarded as the effect of a 
reaction of the tissues against certain chemical substances, whether 
they are produced by living organisms or are purely chemical in 
their nature." 

Cheyne in his excellent article on suppuration is inclined to 
take issue with those who maintain that pus can form without 
bacterial aid. He says: "If a number of careful observers have 
failed entirely to produce suppuration by the injection of these 
irritating chemicals, then those who have obtained a contrary 
result must either have brought some other factor unwittingly 
jinto play, or there must be some other explanation of the result." 
Cheyne, who has carefully gone over the ground, brings forward 
as evidence the results obtained by introducing hermetically-sealed 
sterilized glass tubes, containing a mixture of equal parts of croton 
and olive oil, into the * subcutaneous connective tissue. After the 
wound had healed aseptically the tubes were broken at different 
intervals of time and their contents allowed to escape. He did not 



142 SURGICAL PATHOLOGY AND THERAPEUTICS. 

obtain in any case creamy pus, but ' ' a putty-like mass is formed 
which has been described by some as pus," but which he would 
not regard as such. It is a question, he says, whether this putty- 
like material is not a further change of fibrinous exudations pro- 
duced by the solvent action of the living tissues, which are endeav- 
oring to remove the dead material, and as a result of a prolonged 
action of living cells on the extensive dead mass. 

A number of cases may be found in the quite extensive litera- 
ture of this subject where it is distinctly stated that there was 
obtained a considerable quantity of fluid pus containing no 
bacteria. Steinhaus, who is one of the most accurate investigators 
of this question, has repeated all the experiments with the greatest 
care. He found no irritation resulting from the introduction of 
sealed glass tubes into the subcutaneous tissue: sometimes they 
became encapsuled, but in the peritoneal cavity they were usually 
found floating free. He always obtained pus when calomel was 
used. The ' ' calomel pus ' ' is, however, somewhat different from 
ordinary pus. The nuclei of the cells are single, cystic, or 
elongated, and take staining feebly: there appeared to be an 
advanced degeneration. 

Mercury produced suppuration in dogs, rabbits, and guinea- 
pigs, but the amount of pus produced in the case of the rabbit 
experiments, the only case in which the pus is described, appears 
to have been confined to two small clumps of purulent material 
at each end of the broken glass tube. Nitrate of silver produced 
4 'abscesses" in dogs and in cats: of course the pus contained no 
bacteria. Croton oil produced no pus. It is evident that Stein- 
haus' s experiments with this drug did not differ materially from 
the experiment of Cheyne. Dead cultures of the aureus injected 
into dogs, cats, and rabbits produced pus ' ( which was fully identical 
with the ordinary bacterial pus." Dead cultures of the bacillus 
pyocyaneus produced pus which had all the gross appearances of 
ordinary pus. Steinhaus concludes that suppuration can take 
place without bacteria — that the exciting cause is due to the 
action of certain chemical substances, which are the products of 
decomposition produced by micro-organisms and also of inorganic 
substances like calomel. Other substances than those produced by 
the pyogenic cocci may also cause suppuration: these are the 
ptomaines of putrefaction, like cadaverin. 

From all the above data it must be conceded that it is possible 
to produce suppuration without the direct intervention of bacteria, 
but all are agreed that mechanical irritation or foreign bodies are 



INFECTIVE INFLAMMATION. 143 

unable to produce suppuration without tlic aid of bacteria. A few 
examples have, indeed, been found of suppuration without pus- 
cocci. Rosenbach reported hydatids of the liver as the cause in 
two cases. Baumgarten mentions the jequirity-seed as a cause of 
suppuration as a clinical occurrence. Possibly the number of 
suppurative inflammations in which no organisms can be found 
may with time be increased. Steinhaus suggests that, inasmuch 
as bacteria are cells or cell-like structures which can produce pus, 
under certain circumstances the cells which form the animal 
organism may possibly also produce similar substances. In other 
words, he says: "Are we not justified in establishing a special 
class of autochthonous inflammations?" With our present know- 
ledge, a brief sketch of which has been given in the preceding 
pages, we are not authorized in giving an affirmative answer to 
this question. It would be misleading to do so. 

It should not be assumed that all suppurations are caused only 
by the three or four micro-organisms already mentioned. It 
would be fair to say, however, that the great majority of suppura- 
tions are caused by these forms. The bacillus pyogenes fcetidus 
was found by Passet in the pus of a perirectal abscess; it consists 
of a short staff with rounded ends. The three forms of saprogenic 
bacilli described by Rosenbach seem to , have mild pyogenic 
qualities, probably in virtue of their ptomaine-producing power. 
The bacillus pyocyaneus found in green pus is a short, fine rod, 
and is very likely to be mistaken for a micrococcus. This bacillus 
was not supposed to be pyogenic in action, but, according to 
Steinhaus, its pyogenic qualities have lately been demonstrated. 
H. C. Ernst has recently also described a fluorescent bacillus taken 
from the psoas abscess of a child, which bacillus produced 
abscesses in guinea-pigs on inoculation. Steinhaus has shown 
that the micrococcus tetragenus is capable of producing suppura- 
tion, and he points out that recent experimeutation has demon- 
strated similar qualities in the bacillus anthracis, the typhoid 
bacillus, and the cocci of saliva described by Biondi. Welch and 
others have many times found the bacillus coli communis as the 
cause of suppuration. 

The history of the micro-organisms after their introduction into 
the system must next be followed. This process has been studied 
by injecting pure cultures of the pyogenic organisms into animals 
and examining the animals at varying periods after the operation. 
Ribbert injected cocci taken from an abscess of the bone into the 
blood, and found that they rapidly disappeared. During the first 



144 SURGICAL PATHOLOGY AND THERAPEUTICS. 

twenty-four hours they were found in all the organs, and at the 
end of forty-eight hours in the kidneys only. He concludes, 
therefore, that the first step in the process of infection is a general 
dissemination of the bacteria throughout the body, and that subse- 
quently they disappear from most organs, but remain behind in 
some one organ which contains an embolus or has been damaged. 
Steinhaus injected 0.5 c.cm. of a pure culture of the staphylococ- 
cus into rabbits. No local reaction occurred. The dose was 
probably not large enough, or the animals were not susceptible to 
the particular kind of organism used. At the end of six days the 
animals were killed and cultures were taken from the internal 
organs, growths of the coccus being thus obtained. It appeared 
that the organisms disappeared first from the point of injection, 
next from the liver, then from the kidneys, and finally from the 
spleen at the end of twelve days. No infection took place, the 
cocci being carried from the point where they were introduced 
into the system to the various organs, and were then destroyed, 
many of them being destroyed also at the point of entrance. 

These experiments correspond with Ogston's observation that 
the cocci are present in the blood in septicaemia without producing 
suppuration, and that they are excreted in a living state in the 
urine. Where large numbers are found in the urine Ogston has 
been able to detect the presence of an abscess by the examination 
of the urine alone. In Billroth' s clinique cocci were found by v. 
Eiselberg in the blood of individuals affected with septicaemia and 
traumatic fever, but no cocci were found in the blood of healthy 
individuals. In septic cases micrococci have been found by Stone 
and by the writer in the circulating blood. 

The rapidity with which the bacteria are eliminated from the 
system when they fail to get the upper hand is remarkable. 
According to Cheyne, it is in many cases a matter of minutes 
merely, certainly of an hour or two. Their disappearance, he 
thinks, must be due to an active destructive action upon them of 
the constituents of the blood. Many of the bacteria are probably 
rapidly eliminated by the kidneys; at least their presence has 
frequently been demonstrated in the urine, and masses of cocci 
have been found in the kidneys of children who have died with 
symptoms of acute febrile disorders. 

Experiments on animals with young have shown shortly after 
the injection the presence of bacteria in the milk, and it is sug- 
gested by Cheyne that even the salivary glands and the parotids 
may be called into action. It is probable also that many bacteria 



INFECT1 1 '/•; INFLAMMA TION. 145 

are removed through the intestinal mucous membrane, and some 
have even been traced into the respiratory organs, and have finally 
found their way out of the body in the expectoration. The old 
idea of u appealing to the emunctories M thus receives a scientific 
endorsement. 

When the conditions for suppuration are favorable an injection 
of staphylococci into the subcutaneous tissue of an animal will cause 
an abscess. Baumgarten thus describes the result of such an injec- 
tion : The staphylococci multiply rapidly ; they grow into the 
fibrillated intercellular substance and also into the pre-existing 
cells of the tissue and the vessel-walls ; already twenty-four hours 
after the injection exudation and diapedesis begin ; enormous 
numbers of polynucleated leucocytes are found between the fibres 
of the tissue ; the fibres are more or less swollen, and the lymph- 
spaces are distended and partly filled with large, round, finely- 
granulated cells, which are the altered fixed connective-tissue cells, 
and partly with clumps of leucocytes, near which are seen the 
large cvstic nucleus of the neighboring fixed cell ; the small vessels 
are dilated and distended with blood, and in many places lined 
with leucocytes ; the coccus-growth becomes more and more vigor- 
ous and tends to group into masses ; a number of cocci are found 
in the leucocytes and fixed cells, the thickest growth, indeed, being 
intracellular ; no difference in form or coloring is observed between 
those organisms lying in and those lying between the cells ; in the 
centre of the inflamed focus the coccus-growth and the infiltration 
of leucocytes form a more or less continuous mass, except that the 
cocci still show a tendency to aggregation in groups ; on the 
second or third day the tissues at this point begin to soften and 
liquefy, and the result is an abscess ; at the periphery of the 
inflamed mass the coccus and leucocyte infiltration continues to 
spread ; the cocci grow in thick columns, with small groups here 
and there along their borders, which groups separate and grow into 
the surrounding tissue. 

Bonome, who experimented with the aureus in order to produce 
a lung-abscess to show that the cause of the suppurating abscess 
was not the pneumonia coccus, describes a central necrotic zone 
which included more or less the debris of the leucocytes that had 
immigrated ; outside this necrotic zone was a granular zone of 
leucocytes ; outside this granular zone was a hemorrhagic zone ; 
and surrounding all was a zone of catarrhal pneumonia. This 
formation he terms a furuncle of the lung, and, anatomically con- 
sidered, is a counterpart of what occurs in furuncle of the skin. 
10 



146 SURGICAL PATHOLOGY AND THERAPEUTICS. 

This result is at variance with what Baumgarten observed in his 
subcutaneous injections of staphylococci. Baumgarten attributes 
the occurrence of necrosis of the tissue involved to the number of 
cocci used for the experiment, and he shows that when other 
observers employed much less concentrated doses of these organ- 
isms no such necrosis of the lung took place. Watson Cheyne in 
his lectures on suppuration accepts this view of a coagulation- 
necrosis of the tissues in abscess-formation, and it is therefore 
important to state just what view Baumgarten takes on this point. 
Baumgarten concludes that the occurrence or the non-occurrence 
of such a necrosis depends upon the number of cocci originally 
introduced and on the rapidity of their growth. There may occur 
such a necrosis as Bonome describes in the lung and also in 
furuncle, but it would not probably take place in the subcutaneous 
connective tissue. Necrosis is more likely to occur in tissues not 
richly supplied with blood-vessels, such as the valves of the heart, 
the deleterious action of the cocci being expended upon the tissue 
before diapedesis takes place and the leucocytes make their way 
into the infected district. 

There is a marked difference in the action of the streptococcus. 
It does not possess the same tendency to promote local suppuration 
that is seen in the case of the staphylococcus. It possesses a pecu- 
liar faculty to creep along through the tissues without producing 
suppuration. The short life of the staphylococcus and its tendency 
to break down the tissues do not favor its spreading. According 
to Ogston, after the injection into animals the chains of cocci 
insinuate themselves between the cells and the fibres of the tissue 
and form a sort of network, and a "waxy" change occurs in the 
parts thus involved. Eventually there forms a protecting wall of 
granulation tissue which prevents further progress ; but before this 
wall forms septicaemic symptoms prevail, and micrococci in pairs 
and in chains are found in the blood: as the granulation tissue 
develops the constitutional symptoms subside and the organisms 
disappear. According to Baumgarten, the streptococcus is not so 
well adapted to growth in the body of an animal as the staphylo- 
coccus. When, however, it does grow, it produces a spreading 
inflammation, more like erysipelas, or a superficial form of sup- 
puration with less tendency to a breaking down of the tissue 
involved. It is well to remember here that the behavior of these 
two forms of cocci in the living tissues corresponds with what has 
been noticed in the gelatin-cultures. The staphylococcus exerts a 
strong peptonizing action upon the culture-soil, and liquefaction 



INFECT! I ■/■ IXFLAMM. I TION. 147 

takes place. Its tendency to form pus in the tissues is equally well 
marked. The streptococcus, which does not have the same tend- 
ency to produce suppuration, fails to peptonize and liquefy the 
gelatin. It has been observed, however, that when deprived of 
oxygen the streptococcus does exert a decided peptonizing action 
on boiled albumin and beef; consequently under favoring condi- 
tions it might be expected to cause suppuration, and this action it 
does exert during the later stages of the period of its invasion of 
the tissues. 

As has been seen, it is necessary that a certain number of the 
pyogenic cocci should gain entrance into the system, otherwise 
they soon disappear; but if a sufficient number has taken foothold 
they will be carried into the general circulation, either through the 
lymphatic system by the process known clinically as lymphan- 
gitis, or direct into the venous circulation by gaining an entrance 
to a large vein near the inflamed part. The cocci invade the 
vessel, and there set up an inflammation which terminates in a 
breaking down of the endothelium and the formation of a thrombus. 
(See Pycemia, p. 361.) This thrombo-phlebitis terminates in a 
breaking down of the thrombus, and emboli form, which spread the 
organisms in various directions. When circulating free in the 
blood they soon disappear from the general current, being found 
in the endothelium of the capillaries in organs where the stream 
is slow (as in the marrow of bone), in the glomeruli of the kidney, 
and in the spleen and liver. 

In whatever way they may have been carried to the part, the 
bacteria, when once established there in sufficiently large numbers, 
bring about the formation of an abscess; for instance, a clump of 
cocci, when once caught in the capillary of a kidney, fill out the 
vessel. In the centre of the mass the organisms are hard to dis- 
tinguish, but at its border the individual organisms are distinct. 
The obstruction gives rise to an accumulation of leucocytes, which 
may also be seen within the vessel. The cocci next work their 
way through the capillary wall into the surrounding uriniferous 
tubes, and here is soon seen a change in the character of the kidney 
epithelium, the nuclei losing the staining power and being seen 
only with difficulty. These are the first changes which indicate 
the formation of a coagulation-necrosis of the tissues of the part. 
Leucocytes now emigrate from the neighboring vessels. If the 
district involved is of any size, a portion of the kidney is event- 
ually destroyed, and in the centre of the necrosed portion is found 
a mass of micrococci. This is the type of abscess-formation so well 



148 SURGICAL -PATHOLOGY AND THERAPEUTICS. 

described by Cheyne. He says: "Staining sections of tissue in 
which these plugs are present with ordinary aniline dyes, it is 
found that, while the mass of organisms is internally stained and 
while the nuclei in the section have become well colored, there is 
a ring of tissue around the central mass of organisms which does 
not take on the stain, and which presents a homogeneous, trans- 
lucent appearance. This ring evidently results from the action of 
the concentrated products of the micrococci, the tissue being 
brought into the condition of coagulation-necrosis. After some 
hours a second ring appears at a greater distance from the mass of 
organisms, this ring being composed of a dense layer of leucocytes 
apparently collecting where the chemical substances are more dilute 
and do not interfere with the life of the cells. As time goes on the 
intermediate translucent layer becomes infiltrated, on the one hand 
with cocci from the central plug, and on the other hand with cells 
from the outer ring, and the original tissue rapidly disappears, 
probably as the result of the peptonizing action of the cocci. At 
the same time the fluid effused does not coagulate, probably also 
on account of the peptonizing action of the cocci on the fibrinogen, 
and thus we come to have a central collection of fluids containing 
leucocytes and micrococci, surrounded by a wall of leucocytes and 
cocci — in other words, an abscess. n 

The quality which the streptococcus possesses of producing a coag- 
ulation-necrosis is shown in its tendency, when it invades a mucous 
membrane, to produce a diphtheritic inflammation. This tendency 
is seen in the initial stages of puerperal fever when the vaginal and 
uterine mucous membranes are first invaded by the streptococci. 
The feeble peptonizing power which the streptococcus possesses at 
first appears to gain in strength after remaining some time in the 
tissue, and, accordingly, in the later stages of puerperal fever the 
same organisms seem capable also of developing metastatic suppu- 
ration. In erysipelatous inflammations the streptococcus does not 
remain long enough in the skin to acquire this property; conse- 
quently it is found that abscess-formation in this disease is rare. 
Its growth in the subcutaneous tissues produces at first a fibrinous 
or a sero-fibrinous inflammation; consequently, local circumscribed 
collections of pus or abscess-formations do not take place in many 
cases. 

As already stated, considerable numbers of organisms may be 
injected into the body of an animal and may disappear with great 
rapidity. U?tder what circumstances do we find an active grozvth 
of these organisms ? Cheyne, who has treated this subject at some 



INFECTI\'E INFLAMMATION. 149 

length, first calls attention to a point about which more will be said 
in discussing the etiology of pyaemia. Suffice it to say here that 
certain mechanical conditions are often necessary to enable the cocci 
to obtain a lodgment in the tissues. Thus, Ribbert was unable to 
obtain multiple abscesses in rabbits by injecting moderate quanti- 
ties of cocci into the circulation, but if the organisms were mixed 
with fragments of the potato on which they were grown, he was 
then able to obtain deposits of the organisms in the muscular tis- 
sues of the heart as well as in other organs. 

But it is not simply necessary that the organisms should obtain 
a lodgment: the state of the tissues in which they are arrested is an 
important factor also in the question of suppuration. Experiments 
on animals seem to show that a diminution in the vitality of the 
part is favorable to their development. Thus, Cornil was able to 
obtain septic nephritis by ligaturing the renal arteries for some 
time, and, after removing the ligature, by injecting pyogenic cocci 
into the circulation. 

Analogous to this are the well-known experiments of Kocher, 
who produced osteomyelitis in animals by injecting certain chem- 
ical substances into the medulla of their bones and afterward feed- 
ing them with putrid food. Septic infection, taking place through 
the intestinal canal, found its way to the injured part. The same 
result was obtained by fracturing bones and injecting cocci into the 
circulation. 

Cheyne has studied the influence of inflammation in favoring 
the growth of bacteria in a part. In the first stage of inflammation 
the vital activity of the tissue is suspended; the second stage is 
that of healthy vigorous granulation; and in the third stage the 
cicatricial tissue is a less active type of growth. 

Huber set up an inflammation in a rabbit's ear with croton oil, the other 
ear being left intact for purposes of comparison : anthrax bacilli were then 
injected into the tip of the tail. During the first stage of inflammation there 
was a very marked increase in the number of bacilli in the capillaries of the 
inflamed part as compared with the number present in a similar part of the 
opposite ear. As the inflammation passed into the second stage the number 
of bacilli in the capillaries of the inflamed part gradually diminished, until, 
when this stage was at its height, the bacilli had completely disappeared, 
although they were present in large numbers in the capillaries of the other 
ear. During the third stage, when the inflammation had subsided, the bacilli 
again appeared, and were found in considerable numbers in the newly-formed 
vessels. 

Cheyne argues from these experiments that severe inflammation 
does not tend to a deposit in the part, but that in less severe inflam- 



150 SURGICAL PATHOLOGY AND THERAPEUTICS. 

mation the pyogenic organisms may pass out of the vessels and set 
up suppuration. Thus acute osteomyelitis and local tubercular dis- 
eases frequently stand in some relation to injury. They are not, as 
a rule, attributed to severe injuries, but to some slight blow or a 
sprain. As Cheyne points out, injury is an important predisposing 
cause for suppuration; it may act in two ways: not only in the 
manner above referred to, but also by leading to an effusion of 
blood, thus enabling the pyogenic cocci which may be circulating 
in the blood to pass out of the vessels and find in the cellular tissue 
a suitable place for their development. The laceration of the valves 
as an element in the artificial endocarditis alluded to farther on, 
and the experimental fracture of bones above mentioned, are exam- 
ples of the effects of injury in promoting infection. Anything 
interfering with the integrity of the tissues is a predisposing cause 
of suppuration. Irritation with strong antiseptics may, as Halstead 
has shown, lower the vitality of the surface of a wound and thus 
favor suppuration. Bruising and tension of the tissues are also 
predisposing causes. Dead spaces and foreign bodies remove 
bacteria from the influence of the living tissue and the fluids, 
and thus place them in conditious more favorable for their 
growth. 

The anatomical arrangement of the part may also prove a very 
important factor in the production of suppuration. In acute 
osteomyelitis the inflammation is limited to certain bones and to 
certain parts of bones, such as the epiphyseal line in long bones. 
This predilection may be explained by the presence of a large area 
of growing young tissue, by the vascularity of the part, or by the 
slowness of the circulation. 

The state of the blood is also of importance, as exhibited by the 
well-known tendency of carbuncle to form in cases of diabetes. 
Whether the presence of sugar in the blood directly favors the 
action of the pyogenic cocci does not appear to have been proved 
satisfactorily, and experiments upon this subject are conflicting. 
It is probable that the diminished vitality of the system is a more 
probable cause than the presence of sugar. Gartner's experiments 
show that, with small quantities of the aureus, infection more 
readily takes place in anaemic subjects, thus explaining the 
frequency of boils in individuals who are not in a robust condition 
of health. 

The literature on the question of the season of the year as an 
influence affecting suppurative disease presents nothing of special 
scientific value. In the winter months, when hospital wards are 



INFECTIVE INFL* I MM. I '/VOX. 151 

imperfectly ventilated, the number of cocci in the air is increased. 
In the close and squalid dwellings of the poor in large cities the 
conditions are much more favorable for the growth of pyogenic 
organisms than they are in country dwellings in a good sanitary 
neighborhood. 

According to Cheyne, acute osteomyelitis is reported exceeding- 
ly prevalent in certain parts of Switzerland and Germany, but the 
writer doubts whether locality has any special influence upon the 
disease. Notwithstanding the greater prevalence in Europe of 
bone-deformities from rickets and other diseases, which is apparent 
even to the layman's eye, the writer is inclined to think that 
suppurative diseases of bone occur quite as frequently in America. 

The conclusions which may be drawn from all these studies of 
the etiology of suppuration are — that in man, with few rare excep- 
tions, suppuration is caused by micro-organisms, and that in the 
great majority of cases these organisms are staphylococci or strepto- 
cocci. Experimentally, suppuration can be obtained by purely chem- 
ical substances, such as calomel, or by the ptomaines derived from 
the action of organisms upon living or upon dead substances. The 
practical conclusion to be derived from such experiments is that chem- 
ical substances play a prominent part in the production and the spread 
of suppuration, but they are depende7it upon organisms for their devel- 
opment. These substances are liberated by the cocci either from them- 
selves or from the tissues from which they derive their nourishment. 
The pyogenic cocci cannot, however, always produce suppuration; 
the living healthy tissues are antagonistic to them. They gain an 
entrance and are able to grow only when present in sufficiently 
large numbers. Even then they may be dissipated if the absorp- 
tive power is sufficiently active. But if the vitality of a part is 
lowered by traumatic inflammation, or if there are large effusions 
which cannot readily be absorbed, then they find a soil favorable 
for their growth. The pus-producing power of the pyogenic cocci 
seems to lie in their ability to liquefy the fibrinous exudation of 
inflammation. In large numbers or in certain forms they exert a 
chemical action upon the tissues which produces a necrosis. 
Their elimination from the body may occur either through death 
of the bacteria in various organs or by the action of excretory 
organs. To what extent they are excreted is not yet clear. It is 
probable that the leucocytes are engaged in a struggle with the 
cocci, and that pus exerts a deleterious action upon the organisms 
through the chemical substances evolved. It is probable also that 
bacteria die rapidly in pus from phagocytosis or from starvation, 



152 SURGICAL PATHOLOGY AND THERAPEUTICS. 

and pus is a vehicle in which they are discharged from the body. 
Fatal infections from the cadaver are not usually marked by local 
reactions or by suppuration. The process of suppuration may 
therefore be regarded as serving a useful purpose, and is one of the 
most important weapons employed by nature in resisting the 
invasion of bacteria. 

This branch of the subject cannot be passed by without some 
allusion to the question of immunity. 

Bacteria may bring about diseased conditions by the action of 
an albuminoid substance which they possess in their bodies, and 
which is thought by some to be liberated during the process of 
degeneration of the microbe. This substance is known as a 
bacterial proteid. They may also produce disease by the forma- 
tion of a toxic substance in the tissues during their growth. 

In the former case an intoxication is produced by the absorp- 
tion of a poison developed by the bacteria themselves. In the 
latter case the tissues are so modified by the proteids that there 
is formed in them a chemical substance known as a toxalbumin, 
which, being absorbed, produces the constitutional symptoms, and 
in suppuration causes the destruction and degeneration of the 
attracted leucocytes, which thus collect as pus. 

Immunity is quite a complex condition, and it appears to exist 
in certain individuals in virtue of a chemical substance, found 
there or formed as the result of bacterial action, which is either 
hostile to their development or acts as an antidote to the poison 
they produce. It is also brought about by the action of the 
bacteria in producing an inflammatory reaction in the tissues, as 
the result of which a large number of phagocytes make their 
appearance in the tissues. 

This power of attracting cells is known as chemotaxis, and is 
due to chemical attraction or to irritation produced by the proteids 
of the bacteria. The chemotactic action of pure protein, as it is 
found in cultures of bacteria, is very intense. This attraction can* 
be exerted by bacteria whether living or dead; it is not confined, 
however, to bacteria. Products of other living substances can act 
as chemotactically as those of bacteria. 

The proteid material may also be liberated by disintegrating 
tissues, and the process of absorption may in this way be brought 
about, the leucocytes thus attracted carrying away a certain amount 
of refuse in their bodies. This power is possessed by finely-pow- 
dered substances in different degrees. Gold, silver, and iron exert 
very little irritation of this kind, but copper and mercury are highly 



INFECTIVE INFLAMMATION. 153 

chemotactic. Chemotaxis is said to be positive or negative accord- 
ing as there is attraction or repulsion. 

Metschuikoff thus explains how immunity is effected from a 
certain disease after one attack. Chemotaxis, being variable, may 
be converted from positive to negative, or vice versa. In mild 
forms of infection substances may attract cells which in virulent 
forms they repel. If a mild or attenuated virus is used, chemo- 
taxis, at first negative, will change to positive, and the phagocyte 
will thus be induced to attract or attack the invading element of 
disease. The Metschnikoff school, on the one hand, finds a suffi- 
cient explanation for immunity in phagocytosis alone. The Ger- 
man school, on the other hand, points out that the leucocytes may 
exert a phagocytic action if the bacteria are present, but repair and 
cure may also take place when the chemical products alone of bac- 
teria are present. In such cases they are agreed that the process is 
due to an antidote — a protective or defensive proteid or antitoxine 
— which may be the product of these cells or be furnished from the 
blood. In fact, the normal tissues seem to possess the power of 
rendering inert many kinds of organisms which may have gained 
access to them. The antiseptic properties of blood-serum are now 
generally recognized. These properties are due to the existence 
of a substance known as globulin. Hankin has isolated from the 
spleens and livers of various animals a proteid having the power 
of killing bacteria, and he has found that this substance, though 
absent from normal blood, may be obtained from the blood of 
febrile animals — an interesting point throwing light upon the pro- 
priety of attempts to reduce fever in septic cases. It was therefore 
inferred that those animals which, were refractory to certain dis- 
eases, and those made immune by vaccination, would be able to 
produce defensive proteids; and this has been found to be the case. 

In certain cases the blood-serum is found to destroy the poison 
produced by the bacteria, but not the bacteria themselves; that is, 
the serum is antitoxic. Hankin thus defines immunity: "Immu- 
nity, whether natural or acquired, is due to the presence of sub- 
stances which are formed by the metabolism of the animal rather 
than that of the microbe, and which have the power of destroying 
the microbes against which immunity is possible or the products 
on which their pathogenic action depends." 

If the nature of these protective substances could be determined 
and they could be extracted from the blood, the physician would 
then possess the power of neutralizing disease. Behring and Kita- 
sato have already experimented successfully in this most important 



154 SURGICAL PATHOLOGY AND THERAPEUTICS. 

and suggestive field of therapeutics. They have not only been 
able to render animals immune to certain diseases, and to check 
the course of the disease when it was already well advanced, as in 
hog cholera, but they have also been able to apply these principles 
to certain diseases of man, and their success in the treatment of 
diphtheria and tetanus has raised hopes for a brilliant future in this 
line of therapeutics. 



VII. INFECTIVE INFLAMMATION. 

2. Suppuration. 

Suppuration takes place in the tissues by virtue of the peculiar 
peptonizing or digestive action which the bacteria exert upon them. 
When this action is exerted in an intense degree the chemical sub- 
stances produced bring about a change in the cells and in the inter- 
cellular substance of the part known as coagulation-necrosis, where- 
by the cells grow more indistinct and do not react in a characteristic 
way to staining reagents, and the intercellular substance assumes a 
more or less homogeneous appearance. A necrosis of the tissues is 
not always necessary to produce suppuration, but the changes in 
the affected tissues are what one would expect from an intense irri- 
tation. In the beginning the same changes that occur in the 
lighter forms of inflammation are noticed. Some oedema of the 
part is first observed, with an increase in the size of the fixed cells 
and a proliferation of these cells, and karyokinetic changes may be 
found in many of their nuclei. At the same time there is a large 
accumulation of leucocytes, and the intercellular substance under- 
goes a mucous softening which gives it a homogeneous or a gran- 
ular appearance. The mucous transformation of the intercellular 
substance is the beginning of the softening of the tissues, and at 
this time there may be found, in sections of such tissue, red blood- 
corpuscles mingled with cells in mitosis and young tissue-cells. 
As the zone of pus is approached the leucocytes preponderate over 
all other types of cells, and the intercellular substance becomes 
still softer. At this point also are seen pyogenic organisms in con- 
siderable numbers: as the virus acts more and more intensely on 
the part the cell-structures break down, being digested, as it were, 
by the chemical substances, and the intercellular substance lique- 
fies, and there results a fluid — namely, pus — in place of a solid 
material. 

There are two forms of leucocytes — the single-nucleated and the 
polynucleated. The polynucleated cell, which is the type of the 
pus-corpuscle, possesses two or three nuclei, or peculiarly deformed, 
biscuit- or sickle-shaped nuclei. The nuclear changes are not 

155 



156 SURGICAL PATHOLOGY AND THERAPEUTICS. 

supposed to be those which precede cell-division, but are more 
probably indicative of a breaking down of the nucleus. 

The single-nucleated cell is not seen in large numbers in acute 
inflammation, but in later stages of the latter and in chronic forms 
it is more common. The nucleus is larger than that of the pus- 
cell. It comes from the blood, but the tissue-cells produce also 
similar cells called "wandering cells" (Ziegler). 






•'.'■'X' '-'^^H.-^fir' »» •£»••-» :: % 



Fig. 27. — Metastatic Abscess of Kidney: plugs of micrococci in central necrosis, with sur- 
rounding cell-infiltration (oc. 3, obj. A.). 

If the bacteria have accumulated in a mass at any given point 
— as, for instance, in a capillary loop of the kidney or in the soft 
succulent tissue of a bone — the concentration of the virus produces 
a coagulation-necrosis of the immediately surrounding tissue, and 
there is developed a central point around which the abscess forms. 
The leucocytes soon accumulate in enormous numbers around such 
a mass of dead tissue, and. if the abscess is examined at this stage 
there will be found in the centre of it a cluster of micrococci 
imbedded in a mass of necrosed tissue, forming a more or less 
transparent zone around them (Fig. 27). Surrounding this mass 
of broken-down tissue is a wall of leucocytes. As the abscess 
grows in size the leucocytes wander into the necrosed area and 
mingle with the micrococci. Many of the foremost ranks of the 
walls of leucocytes are separated from their neighbors by the lique- 
faction of the intercellular substance, which liquefaction is caused 



INFECTIVE INFLAMMA TION. 



157 



bv the peptonizing' action of the bacteria. In this way the area 
of fluid material is constantly enlarged. In the outer portion of 
the wall of leucocytes many fixed cells of the surrounding tissue 
are to be found in a state of proliferation. The growth of the 
abscess-cavity is caused by the bacteria invading the surround- 
ing tissues and the progressive softening which takes place in 
the way indicated. The tension of the tissues over some point 
in the abscess-cavity becomes very great from the pressure of the 
enclosed fluid, and the vitality of the tissue is also impaired by 
the septic infection; softening or necrosis takes place, and the 
abscess "points" and breaks and the contents are discharged. 
An abscess may therefore be defined as a circumscribed collec- 
tion of pus. 

The tissue lining the walls of the abscess-cavity is called " gran- 
ulation tissue," and it is bv the growth of this tissue that the cav- 
ity is filled up and repair is effected. The tissue thus formed con- 
sists chiefly of small round cells with very little intercellular 
substance, and is very rich in capillary blood-vessels. The poly- 
nucleated cells, which are numerous, are cells which are breaking 




. - .. 



Fig. 28. — Portion of Wall of Lung-abscess, natural injection (oc. 3, obj. A.). 



down and about to be thrown off from the surface as pus-corpuscles 
or to be absorbed or to serve as food for the cells which are building 
up new tissue. There are also a number of leucocytes with single 



158 SURGICAL PATHOLOGY AND THERAPEUTICS. 

nuclei, and of larger cells each with a large oval bright nucleus, 
which are called ''epithelioid cells" from their resemblance to epi- 
thelium. These cells are also called " fibroblasts," which presently 
become more numerous than the pus-cells, and which are the active 
agents in the process of repair, as will presently be seen. 

The wall of the cavity is at first lined with pus and shreds of 
broken-down tissue, but when all this has been discharged the 
lining membrane is found to consist of a richly vascular tissue 
studded with numerous little red nodules, which are called "gran- 
ulations," and the tissue of which they are composed is the gran- 
ulation tissue above described (Fig. 28). 

The group of symptoms which characterize suppuration gives a 
picture of septic inflammation of the most marked type. The for- 
mation of an abscess is accompanied by a great amount of swelling 
of the surrounding tissues, which are made tense and brawny by 
the exudation with which they are infiltrated. A bright red blush 
extends even to the surrounding tissues. As the tension increases 
the pain becomes acute and is of a throbbing or of a boring cha- 
racter. The constitutional disturbance is also great, and the advent 
of suppuration is usually indicated either by a chill or by a sudden 
rise of temperature. 

As the pus approaches the surface the tissues near the centre of 
the inflamed area become softer, and on pressure with the fingers 
are said to "fluctuate." The integuments, however, are tense, and 
they become stretched and thinner, and finally a whitish spot indi- 
cates the near approach to the surface of the fluid contents of the 
abscess. At this stage the pain is most acute and the febrile dis- 
turbance is usually at its highest point. When the abscess breaks 
and the pus discharges freely, both local and constitutional symp- 
toms subside. 

The surface of the abscess-wall is now found covered with shreds 
of broken-down tissue. On scraping this tissue away a layer of 
firmer tissue, the granulation tissue is reached which separates the 
suppurating area from the surrounding tissues. In two or three 
days the wound ' ' cleans off, ' ' and the shreds are discharged with a 
flow of pus, and red granulations are seen lining the walls of the 
cavity. 

Pus is a yellowish-white substance of the consistency of cream, 
and, in what may be said to be its natural condition, is odorless and 
has an alkaline or faintly acid reaction; under the microscope pus 
is found to contain a large number of cells known as pus-corpuscles. 
When this fluid is allowed to stand for several hours a sediment is 



INFECTIVE INFLAMMATION. 



J 59 



formed which is composed almost entirely of these corpuscles. 
There are also found some broken-down tissue-cells, fragments of 
fibrous tissue, and various forms of bacteria, principally the pyo- 
genic cocci (Fig. 29). There is a certain amount of granular debris, 



::T«r 



A 



i 






"v 



Fig. 29. — Pus-cells with Staphylococci. 

which is the result of the breaking down of leucocytes and blood- 
plaques. The liquor puris, or pus-serum, is a pale, yellowish fluid, 
which differs somewhat from blood-serum in containing the prod- 
ucts of the decomposition of tissues during the suppurative process, 
such as leucin and tyrosin. Pus-serum also contains a substance 
known as peptone. The principal source of the pus-cells is the 




Fig. 30. — Pus-cells treated with Acetic Acid, and Crenated Red Blood-corpuscles (oc. 4, 

obj. D.). 



blood, from which the leucocytes migrate to the focus of suppura- 
tion. When treated with acetic acid and the various staining 



i6o 



SURGICAL PATHOLOGY AND THERAPEUTICS. 




methods these corpuscles (Fig. 30) are found to contain several 
nuclei. This polynuclear condition is not a sign of cell-activity, 
but rather one of degeneration. Many of the cells, however, when 
examined in the fresh state, have amoeboid movements. The tis- 
sue-cells are represented to a certain extent among the pus-corpus- 
cles, but their number is quite limited. The polynuclear leucocyte 
should therefore be regarded as the type of the pus-corpuscle. 
Micrococci are rarely seen in the interior of pus-cells, but they are 
usually found between them floating in the pus-serum. Pus was 
formerly known as good or laudable pus. Until recently several 
varieties of pus have been described, but the names given to them 
are now but little used. 

Ichor is a name given to pus in a state of decomposition. The 
pus-cells are few in number and the bacteria of 
decomposition abound. 

Sanies is pus usually in a more or less decom- 
posed condition, and is mixed with blood. These 
forms of pus are very irritating and have either 
a strongly acid or an ammoniacal reaction. 

Blue pus is caused by the presence of the 
bacillus pyocyaneus. It has no special sig- 
nificance and is rarely seen. In acute forms 
of septic inflammation deposits of an orange 
color are occasionally found on suppurating sur- 
faces. This color is due to the presence of 
hsematoidin crystals, the result of the presence 
of red corpuscles in the exudation. It is 
thought by Verneuil to indicate an unfavorable 
prognosis. 

Tubercular pus, which is a pale, chalky 
fluid, contains but few pus-corpuscles and no 
pyogenic cocci. The sediment consists of the 
products of broken-down tissue and of a few 
tubercle bacilli. 

Red pus has recently been described by 
Ferchmin. It is said to be due to the pres- 
ence of a bacillus whose length is about one- 
third the diameter of a red blood-corpuscle. 
The bacillus has no spontaneous movements 
and is colorless, but it is readily stained by 
Gram's method. It grows best at a temper- 
The cultures on blood-serum have a bright red 




Fig. 31. — Sterilized 
Test-tube and Swab 
for collecting pus and 
fluids for bacteriolog- 
ical examination. 



ature of 36 C. 



INFECT! I "/•: tNFL* I MM. I TION. 161 

color, which later changes to violet. It was observed in fourteen 
cases in the clinic at Charkow. The red pus is best seen on the 
white dressings when first removed. It can readily be distinguished 
from blood with little practice. If allowed to dry upon the dress- 
ing, it does not change color, whereas blood spots soon become a 
dirty-brown color. 

3. Abscess. 

Abscesses may in a general way be classified (1) as superficial or 
subcutaneous, and (2) as deep-seated or subfascial. The pus as it 
forms spreads in the direction of least resistance, and an abscess 
may thus become very greatly enlarged. The loose subcutaneous 
tissue offers a favorable route for the extension of the inflammatory 
process, while the fascia presents great resistance, so that the 
superficial abscess may spread horizontally for a considerable 
distance, instead of burrowing down into the tissues beneath. 

The subfascial abscess dissects its way along the sheaths of the 
muscles and blood-vessels, and may even separate the periosteum 
from the bone. The anatomical arrangement of the fasciae and 
the space which they enclose often determines the route these 
abscesses pursue. 

In the neck, for instance, will be found the deep cervical 
abscess, which forms in the upper triangle of the neck in one of 
the lymphatic glands situated near the angle of the jaw, and 
burrows downward, sometimes to the anterior mediastinum, owing 
to its inability to penetrate the deep layer of the cervical fascia. 
A still deeper abscess in this region is the retropharyngeal, or the 
" retrovisceral abscess," as it is sometimes called. This abscess 
occupies the space between the oesophagus and spine, which space 
is filled with loose connective tissue, permitting the pus to burrow 
downward into the posterior mediastinum. Laterally, this space 
is shut in by the sheath of the blood-vessels, which is quite 
unyielding in the upper portion of the neck, but at the level of 
the inferior thyroid artery the connective tissue becomes loose 
again, and permits pus to escape from the retrovisceral space into 
the previsceral region, where it may burrow upward in front of the 
carotid sheath. These spaces may artificially be injected in the 
cadaver through a canula introduced beneath the mucous mem- 
brane of the pharynx, through which fluid can be forced from 
the posterior space along the sheath of the inferior thyroid artery 
to the anterior spaces of the neck. Pus in this region may find its 

way to the surface near the angle of the jaw, but more frequently 
11 



162 SURGICAL PATHOLOGY AND THERAPEUTICS. 

it burrows downward in the way indicated. Such an abscess 
usually originates from a tubercular nodule in the body of a 
vertebra. The subfascial abscess may also take its origin from an 
inflammation arising from an adjacent organ, as the kidney, 
giving rise in this case to the so-called ' ' perinephritic abscess. ' ' 

The earliest symptoms of such deep abscesses are of a subjective 
nature. A slight oedema may be seen locally at first, but no 
swelling nor redness. In a few days there is evidence of deep- 
seated infiltration and the part becomes tender on pressure. As 
the inflammation approaches the surface all the symptoms become 
more marked. Several days may elapse, however, before the pus 
reaches the surface. At this time the skin is tense and of a scarlet 
redness, the contour of the adjacent parts is lost, and there are 
dense infiltration and oedema of the surrounding tissues. When 
the pus is discharged foreign substances may be found mixed with 
it, such as faeces, urine, or fragments of bone, according to the 
source from which it comes. 

Phlegmonous inflammation is a term given to the spreading 
forms of suppuration, such as are usually produced by the invasion 
of the streptococci. Here all the signs of acute inflammation are 
present and- the area involved is extensive. The connective tissue 
and the lymphatics are the routes through which the streptococci 
spread. These organisms do not cause suppuration at first, but as 
they grow they exert a poisonous influence upon the tissues wide- 
spread in its effects. If an incision is made into the part during 
the early stage of the process, there is set free a more or less clear, 
yellowish fluid, wmich may contain a few pus-cells or flakes of 
fibrin. Nearer the central point of the inflammatory process the 
cut surface has a pork-like aspect. As the streptococci develop in 
the tissues more extensively, a coagulation-necrosis results from 
the intensity of the virus, and finally foci of suppuration are 
established. A considerable portion of the tissue may become 
necrosed, with the formation of sloughs, and the skin may become 
separated from the parts beneath. In many portions of the 
inflamed part the veins are found to be filled with thrombi, and 
when such tissues are incised the amount of bleeding is often 
strikingly small. 

This form of inflammation is usually accompanied by an 
cedematous swelling of the parts. In the more central portion the 
tissues become hardened and brawny, and the natural folds of the 
region are more or less completely effaced. On the surface of the 
distended skin appear vesicles filled with red or yellow serum. 



INFECTIVE INFLAMMATION. 163 

The constitutional disturbance is usually profound and of a septi- 
cemic character. When suppuration is established, pus may 
come to the surface at one or more points. If the pus be evacu- 
ated and the finger be introduced through the opening made, a 
series of spaces are felt between the skin and the muscles, or the 
pus may be found to have burrowed between the muscles and 
vessels down to the periosteum. The type of such an inflamma- 
tion may be found in those septic processes which develop in the 
hand and spread rapidly up the arm. Here is found not only a 
continuous spreading inflammation of the connective tissue, but 
also an involvement of the lymphatics, as shown by red lines run- 
ning along the inner aspect of the arm to the group of glands at 
the elbow or the axilla. Occasionally the suppurative process will 
develop itself at one of these two points, a protective influence 
being thus exerted by the lymphatic glands, by which a further 
spread of the process is prevented. A good example of phleg- 
monous inflammation is seen also in a case of compound fracture 
which has become septic. In fractures of the leg of this type the 
soft parts extending from the ankle to the knee may thus become 
involved. The most severe form of this inflammation is seen in 
phlegmonous erysipelas. 

In rare instances a more grave type of inflammation is 
developed, known as malignant oedema. In this type the rapidity 
and intensity of the process are such that the tissues seem to 
become extensively necrosed, or the patient succumbs to acute 
septicaemia before suppuration is established. The streptococcus 
frequently plays a prominent part in this inflammation, though 
occasionally there is found the organism known as the bacillus of 
malignant oedema. A whole extremity may become involved 
within from twenty-four to thirty-six hours in a diffused cedema- 
tous swelling. The skin is not reddened, but has a brownish 
color, and becomes still more discolored, and later assumes a more 
or less cadaveric appearance. In the early stages an incision 
evacuates only a serous fluid which here and there has a slightly 
turbid appearance, suggestive of the presence of pus-corpuscles. 
Later, free and deep incisions show that the process has involved 
all the soft parts of the limb, and that the subcutaneous tissues, 
and even the muscles, may have become gangrenous. 

An example of this type of inflammation was seen a few years 
ago in the case of a medical student. The young man, who had 
been in somewhat feeble health, had wounded a finger in the dis- 
secting-room. When seen on the second day of the disease the 



164 SURGICAL PATHOLOGY AXD THERAPEUTICS. 

whole arm to the shoulder had become involved, and the process 
had extended to the adjacent tissues of the thorax. Free incisions 
were made by his surgeon over the pectoral muscles and into the 
upper part of the arm, which incisions gave vent to an abundant 
flow of a slightly turbid serum, no pus being found anvwhere. 
The process could not be arrested, and the patient succumbed to 
septicaemia on the following day. 

An elderly carpenter came into the hospital recently with an 
injury of his hand from a splinter of wood. The whole upper 
extremity* was involved in a septic process of three days' standi::^, 
and the constitutional disturbance was profound. The patient 
etherized, and free incisions showed that pus had burrowed into 
the deepest intermuscular spaces and that the connective tissue was 
everywhere gangrenous. The operation gave no relief, and the 
patient died of a typical acute septicaemia on the following day. 

The treatment of a circumscribed abscess consists in early incis- 
ion for the evacuation of pus. The old method consisted in the 
application of poultices until the abscess "pointed,'* when an 
incision hastened the escape of pus by a few hours only. In many 
cases such delay may endanger important structures and allow the 
abscess to attain a size which will require a longtime for the wound 
to heal. An incision should therefore always be made as soon as 
the diagnosis of suppuration is established. The only exceptions to 
be given to this rule are those cases in which the abscess is not 
liable to spread and involve important structures, and in which the 
patient prefers to wait for the slower method of Nature. 

Antiseptic precaution should not be relaxed in these operations 
The parts should be cleaned thoroughly beforehand, and the ope- 
rating instruments and the hands of the operator should be disin- 
fected. A clean-cut incision should be made of sufficient length to 
keep open the most prominent or the most dependent part of the 
abscess throughout its whole length. In very large abscesses it 
may be preferable to limit the length of the incision and make, if 
necessary, a counter-opening. Very long incisions are rarely neces- 
sary where the suppuration is circumscribed. When the opening 
has been made the edges of the wound should be separated and the 
inner surface of the cavity- be inspected, all sloughs and infected 
tissne being removed as carefully as circumstances permit. This 
removal can best be performed with a sharp curette. The wound 
should then be irrigated with a solution of corrosive sublimate of 
a strength of I : iooo or i : 5000, and, after drying, it should be 
stuffed with iodoform gauze and a dry dressing applied: or there 



INFECTIVE INFLAMMATION. 165 

may be employed an antiseptic poultice consisting of absorbent 
cotton soaked in a very weak solution of carbolic acid or creoline 
or corrosive sublimate (1 : 20,000). An antiseptic poultice should 
always be used when the incision has not been large enough to lay 
the cavity thoroughly open, and the cavity should be drained by 
a rubber tube inserted through the wound. These wet dressings 
should be changed every two or three hours when the discharge is 
free. The dry dressing may be allowed to remain for twenty-four 
hours, or even longer when the infected tissues have been thor- 
oughly removed. When the latter method is successfully employed, 
all further infection is checked, the inflammation subsides, and the 
wound becomes in two or three days a healthy granulating surface. 

Every abscess should be thoroughly disinfected when it is pos- 
sible to do so. Prompt and energetic treatment of this kind is 
especially indicated in abscesses involving a portion of the perito- 
neal cavity to ward off a general peritonitis, or in the neighborhood 
of the rectum to avoid the occurrence of a fistula in ano. Deep- 
seated abscesses of the neck come within this category, as they are 
liable to burrow freely among important anatomical regions, and 
may cause dyspnoea or sudden death by pressure upon the trachea 
or the recurrent laryngeal nerve. Abscesses of the breast, if not 
opened and drained freely, may lead to extension of the suppura- 
tion and to the formation of multiple abscesses. If a mammary 
abscess is carefully curetted, and is so situated that a counter-open- 
ing can be made or that the opening can be made sufficiently large, 
it may be stuffed with iodoform gauze and all further infection of 
the gland prevented. Such abscesses heal slowly, however, owing 
to the discharge of milk into them from the lacteal ducts. The 
gravest injury may be inflicted upon the medullary cavity of a bone 
by allowing a case of acute osteomyelitis to run its course without 
intervention. 

It is rare that one regrets a free and early incision ; conversely, 
punctures or small cuts, which are sometimes described as "med- 
ical incisions," are likely to produce an increase of all the symp- 
toms, owing to the introduction of fresh sources of infection through 
the cut surfaces and to the plugging up of the opening by blood- 
clot. 

In abscesses of internal organs, such as empyema, perinephritic 
abscess, or abscess of the appendix, the operation required is one 
of major importance. The point of election in these various cases 
must carefully be selected, and the parts must be divided with the 
care commensurate with their anatomical importance. In empyema 



1 66 SURGICAL PATHOLOGY AND THERAPEUTICS. 

it may be necessary to resect a portion of one or more ribs, partly 
for the purpose of drainage and partly to allow collapse of the other- 
wise rigid wall, for it is by contraction of the abscess- walls, as well 
as by the process of granulation, that an abscess-cavity heals. 

In the spreading forms of suppuration, or phlegmonous inflam- 
mation, the necessity of a prompt intervention on the part of the 
surgeon is still more strongly called for. The indications in such 
cases are to reach the micro-organisms at all points where they 
are growing actively in the tissues, and to attack them with all 
the resources of antiseptic methods. Their further progress must 
promptly be arrested. To accomplish this result it is manifestly 
futile to content one's self with the simple opening of a pus-cav- 
ity: such a procedure may aggravate what is already a grave con- 
dition. Organisms which have perhaps been held in check by an 
insufficient supply of oxygen may gain new force or new forms of 
bacteria may be introduced. At all events, it is not uncommon to 
find symptoms of septicaemia developing when an acute and deep- 
seated suppuration has been opened insufficiently. 

Free incisions, therefore, are indicated, and pus should relent- 
lessly be followed to the farthest point of the suppurating tissue. 
When the area involved is an extensive one, it may be preferable 
to make multiple short incisions, so arranged that drainage may 
satisfactorily be obtained and that the scar may be so situated as 
not to interfere with the function of the part. An attempt should 
be made to remove as much as possible of the necrosed tissues, and 
great pains should be taken to disinfect all exposed surfaces by free 
douching with antiseptic washes. After the wounds have been 
dried they can be packed with iodoform gauze, or rubber drainage- 
tubes should be inserted freely. The part should then be enveloped 
in a large antiseptic poultice or in a voluminous dry absorbent 
dressing. These dressings should be changed frequently, and 
attempts should be continued to keep down the septic fermentation. 
The healing of such a pus-cavity or series of cavities must neces- 
sarily be slow. 

In the early stages of malignant oedema, while a soft ©edematous 
swelling exists, several free incisions through the integuments may 
suffice to arrest the process. Usually the disease spreads so rapidly 
that abortive treatment cannot be employed. When the oedema is 
very extensive Volkmann's method of multiple scarifications has 
been used with success. This consists in making, with a narrow 
and sharp-pointed knife, a very large number of small incisions 
through the skin into the subcutaneous tissue. These incisions 



INFECTIVE INFLAMMATION. 167 

should be from 2 to 3 mm. long, and may in some cases amount to 
several hundred in number. The bleeding soon ceases, and a clear 
serum presently exudes freely from the various punctures. The 
flow of serum may be favored by warm douches of 2 l 2 per cent. 
solution of carbolic acid or by mild solutions of corrosive subli- 
mate. Gentle stroking with the hand from the base to the tip of 
the extremity also favors the flow. At the end of fifteen minutes 
the size of the limb will greatly be reduced and many micro-organ- 
isms will have been removed from the infected tissue. Disinfection 
is then brought about by sponging the incisions with antiseptic 
solutions. 

The limb should now be enveloped in iodoform gauze or in 
some form of antiseptic poultice. Frequent antiseptic baths or 
permanent irrigation may also be used. 

When the disease is further advanced and deeper tissues are 
involved, this method will not suffice to arrest the process. A more 
radical treatment is then indicated: the incisions must be longer 
and deeper; all septic foci must be laid open thoroughly, even if 
it be necessarv to cut down to the bone; the masses of sloughing 
tissue must be excised, and all the interspaces laid open must be 
irrigated freelv; abscess-cavities should be curetted thorousrhlv; 
and the thrombosed veins should be ligatured and excised. In 
short, no effort should be spared to remove the septic material. 
Before applying the dressing the limb may be placed for ten or 
fifteen minutes in a warm solution of corrosive sublimate of 1 : 
3000. A dry iodoform dressing should then be applied with firm 
pressure. If such method of treatment fails to arrest the septic 
process, the limb should be amputated at a point as near as pos- 
sible to the healthy tissues. The internal treatment consists in the 
free use of alcoholic stimulants. Strychnine, nitro-glycerin, and 
digitalis may be used when the pulse indicates a feeble action of 
the heart. 

The patient should be kept in bed and the limb should be 
placed in a comfortable position on a pillow. Opium may be 
given to relieve pain and to ensure rest for the patient. The 
starting-point of many of these serious types of phlegmonous 
inflammation is in the hand. It is well to consider some of the 
commoner forms of suppuration occurring in this locality. 

Panaritium (a corruption from paronychia, -and and ow£ . 
whitlow, and felon are names used to indicate inflammation situ- 
ated in the ends of the fingers and in the hand. These inflamma- 
tions may take their origin either in the skin, in the subcutaneous 



1 68 SURGICAL PATHOLOGY AND THERAPEUTICS. 

cellular tissue, in the tendons, in the periosteum, or in the bones 
and joints. 

The infection takes place through some point of injury in the 
skin. The masses of thickened epidermis on the hands of labor- 
ing-men may become bruised or torn or blistered, and the presence 
of numerous micro-organisms gives conditions favorable for infec- 
tion. Slight punctured wounds in the hands of carpenters made 
by splinters of wood may often become very dangerous ; the 
butcher or the cook may become infected by putrid meat through 
cracks or fissures in the skin. Dissection or operation wounds may 
be followed by a similar infection. The anatomical arrangement 
of the connective-tissue fibres on the palmar surface of the hand 
and fingers is such that they run perpendicularly inward to the 
palmar fascia or the sheaths of the tendons, and infective material 
is for this reason readily directed to the deeper parts. The penetra- 
tion of this fascia produces a division of the abscess into super- 
ficial and deep portions, which are united by a narrow sinus. This 
form, known as the "shirt-stud" abscess, should not be overlooked, 
as the pus may continue to burrow beneath the fascia even after a 
superficial opening has been made. When the virus reaches the 
sheaths of the tendons it spreads rapidly along the channels thus 
afforded to it. ' On the dorsum of the hand the subcutaneous 
fibres run horizontally, and the inflammation therefore remains 
more superficial and does not so readily involve the tendons. 

Panaritium aitaneiim, or the cutaneous form of felon, closely 
resembles a boil. The felon occurs by infection through a wound 
or an abrasion, and is more likely to be found in the young, whose 
skin is tender. In older people the skin, being hardened and thick- 
ened by work, serves as a protection. The virus penetrates the 
skin covering the finger-pulp, and makes its way between the 
vertical bundles into the lobules of fatty tissue lying beneath. 
The dense fibrous septa prevent the further spreading of the virus 
and confine it to a limited area, as in the case of a furuncle or boil. 

As the minute abscess develops the dense bands of fibres are put 
upon the stretch. The pulp of the finger is red and painful, and 
the affected tissues form a dense and well-defined swelling. It is 
often difficult to determine the exact point of suppuration, but a 
careful localization of the most painful spot will enable one to 
determine its locality. If left to itself, the abscess will finally 
"point," the pus will be discharged, and with it a slough or 
( ' core ' ' very similar to that seen in the boil. 

Very intense forms of inflammation of this kind may lead to 



INFECTIVE INFLAMMATION. 



169 



gangrene of the skin or of a portion of the finger. It is well to 
remember this tendency of the disease in applying carbolic lotions, 
which have in some recorded cases produced gangrene. Lymphan- 
gitis may also be a complication of this form of felon. The dis- 
ease begins with a chill and considerable fever. Red lines are seen 
running along the dorsum of the hand and the forearm to the 
elbow-joint or to the axilla. The lymphatic glands at these two 
points may become involved in the inflammation, and suppuration 
may take place. 

Panaritium tendinosnm occurs most frequently when the sub- 
cutaneous form burrows more deeply and the sheath of the tendon 
becomes infected. The virus is then rapidly carried along the 
volar aspect of the finger. The tendon-sheaths of the three middle 
fingers do not extend beyond the heads 
of the metacarpal bones, while those of 
the little finger and the thumb are con- 
tinuous with the bursa of the palm of 
the hand and extend beneath the annu- 
lar ligament Of the wrist (Fig. 32). For 
this reason a felon of the thumb or of 
the little finger is more liable to spread 
into the palm of the hand, whereas a 
felon on either of the three middle fin- 
gers is more likely to remain confined 
to those fingers. For these anatomical 
reasons it is easy to see that the prog- 
nosis of a suppurative process involving 
the tendon-sheath is more unfavorable 
than that in the superficial variety. 

The periosteal form of felon may 
arise primarily from a puncture reach- 
ing the bone, or secondarily from a sup- 
puration extending downward from a 
more superficial part. This form of 

felon occurs most frequently on the terminal phalanx. In the 
other phalanges the periostitis is usually secondary to a tendo-vagi- 
nitis above described. Such a periostitis may lead to necrosis of 
the phalanx involved or to suppuration of the adjacent joint. 

Clinically, it is not usually easy to make a differential diagnosis 
between the different forms of felon, but the periosteal form may 
be recognized by the peculiar boring character of the pain and the 
greater length of time needed for the pus to come to the surface. 




Fig. 32. — Diagram of Tendon- 
sheaths of the Hand (Tillaux). 



170 SURGICAL PATHOLOGY AXD THERAPEUTICS. 

The treatment of a felon consists in early laying open the 
inflamed focus. It is rare that such a septic inflammation can be 
aborted. Early attention to slight injuries about the ends of the 
fingers, particularly by those who are obliged to come in contact 
with septic material, may often prevent the establishment of a 
superficial focus of infection. Even- slight scratch and hang-nail 
should carefully be attended to by the surgeon who desires to keep 
his hands in proper condition for operation. A rubber cot applied 
for a few hours will favor a discharge of serum which will float 
away any poisonous substance that might readily multiply itself 
if allowed to remain beneath a dried crust or a clot. The frequent 
use of antiseptics is a great protection which the surgeons of a 
former generation did not enjoy; consequently "septic fingers' ' 
were then much commoner than they are to-day. 

If suppuration is established, the pus-cavity should promptly be 
opened, and the incision should if necessary be carried down to the 
bone. An incision should also be made promptly in the more 
severe types of felon before suppuration has been established, as 
the tension of the parts is thus relieved and the further spread of 
the virus is prevented. It should, moreover, be the province of 
the operator to clean out the pus-cavity and to remove all infected 
tissue, so that the danger of the spreading of the virus may be 
reduced to a minimum. 

Many of these felons can be opened with the assistance of a local 
anaesthetic, such as cocaine. A rubber tubing should be tied 
around the root of the finger, and a 2 per cent, solution of cocaine 
should be injected on either side along the course of the nerves. 
If the tendon-sheaths are involved and a more extensive operation 
is required, it is better to etherize the patient. The part should be 
rendered bloodless, and the burrowing pus should be followed in 
even' direction. 

The dressing for these wounds should be in the nature of an 
antiseptic poultice, for in this way the danger of the retention of 
any poisonous secretion is greatly diminished. Small areas of bone 
may be laid bare in felon of the terminal phalanx without neces- 
sarily involving the death of the bone. It occasionally happens in 
a neglected felon, however, that the periosteum of the bone may 
be dissected completely away from it, and the bone then lies like a 
foreign body in the centre of an abscess. If a joint is involved, 
the best that can be hoped for is an ankylosis. 

The importance of promptly attending to these abscesses cannot 
too strongly be urged upon the surgeon, for they involve an organ 



INFECTIVE INFLAMMATION. 171 

which is of the utmost importance to all classes of individuals, 
especially so to those who are dependent upon their hands for their 
support. 

& palmar abscess originates in the callosities which form over 
the metacarpal bones, and which develop as the result of unusual 
pressure or of friction from work. A fissure in these callosities or 
the formation of a blister may furnish the entrance-point of an 
infection. The subcutaneous tissue, when bruised by unusual vio- 
lence, may also favor such an infection. Palmar abscess may be 
superficial or may be deep. The latter variety owes its importance 
to the presence above it of the palmar fascia, which offers a serious 
obstacle to the escape of pus toward the surface. The pus, there- 
fore, burrows among the sheaths of the tendons, and may find its 
way between the metacarpal bones to the dorsal surface of the 
hand. As the abscess forms the tension produced by the pressure 
upon the palmar fascia is very great, and the pain is correspond- 
ingly severe. For the same reason the swelling is not so pro- 
nounced as in corresponding inflammation elsewhere. Redness is 
also less marked on account of the thickened epidermis. There 
is, however, in many cases an cedematous swelling which may lead 
to the supposition that the seat of the abscess is in this region. 

As has been stated, the infection may occur beneath the palmar 
fascia secondarily, having worked its way down along the sheath 
of a tendon from one of the fingers. In severe cases the whole 
hand may be involved. The tissues then are greatly swollen and 
the natural furrows of the hand disappear. The fingers are flexed 
and the hand assumes a claw-like aspect. The suppurative 
process will not remain long confined to the hand, for the pus 
readily burrows under the annular ligament, and gives signs of its 
presence by symptoms of inflammation on the anterior aspect of 
the wrist. If neglected, the area of suppuration may extend to 
the region of the muscular tissue of the forearm. There is more 
or less constitutional disturbance in palmar abscess, according to 
the extent or the severity of the inflammation. 

Careful rules are usually given to enable the operator to avoid 
the palmar arch. The general rule of following the prolongation 
of the axes of the fingers and of keeping below the fold of the 
thumb is usually sufficient. By carefully determining the seat of 
the pus the knife may be used without fear, and when the pus- 
cavity has been opened its various ramifications should be followed 
to their farthest point of extension. A long incision is usually 
unnecessary. Counter-openings are preferable when the sinus is a 



172 SURGICAL PATHOLOGY AND THERAPEUTICS. 

long one. In very severe types of inflammation it may be 
necessary to disregard all anatomical rules and lay open even the 
annular ligament. Difficulty in controlling hemorrhage rarely 
occurs, even if the arch is divided. After a prolonged bath in 
some warm antiseptic solution the hand should be placed in a 
large antiseptic poultice reaching nearly to the elbow. If the case 
is a serious one, the patient should be placed in bed and the arm 
allowed to lie upon a pillow, the hand being slightly elevated. 
Serious contraction of the fingers may occur, being due to slough- 
ing of the tendons or the formation of cicatricial bands. 

Abscesses of the skin comprise pustules, boils, and carbuncles. 
These affections are caused by invasion of pyogenic cocci from the 
layers of epidermis down the hair-sheath to various depths in the 
skin and subcutaneous tissue. When the micro-organisms pene- 
trate the hair-follicles as far as the sebaceous glands and then 
germinate, there results a pustule similar to that seen in acne. It 
appears as a small nodule in the upper layers of the skin, and 
varies in size from a pin's head to a pea, according as the seat of 
the pustules is in the duct of the sweat-gland, or in the glands of 
the lanugo hairs, or in the large sebaceous glands. The inflam- 
mation is usually preceded by an accumulation of sebaceous 
matter in the .gland. 

The boil or furuncle is caused by invasion of bacteria to a 
deeper portion of the skin, either through the same route as in 
the case of the acne pustule or through the sudoriparous gland- 
ducts. The commoner of the two routes is the former. The 
seat of the boil in this case is the deeper layers of the cutis and 
the subcutaneous cellular tissue. The active growth of the 
bacteria produces in the connective-tissue fibres a coagulation- 
necrosis, which subsequently forms the ' ' core ' ' of the boil. The 
part thus destroyed and cast off consists, according to Neumann, 
of the sebaceous gland and the accompanying hair-follicle. 
Undoubtedly, the commonest origin of boils is infection through 
the hair-follicles and sudoriparous gland-ducts of the skin. This 
was conclusively shown by the well-known experiment of Garre 
(page 138). Clinical experience confirms this view, and explains 
the contagiousness of furuncles and the means by which they are 
communicated to different parts of the skin of the same individual 
or from one individual to another (acne contagiosa). Athletes 
undergoing severe training are liable to boils. This tendency is 
due either to an enfeebled condition of the system or to the bruis- 
ing of the skin, usually that of the nates, and to infection from 



INFECTIVE INFLAMMATION. 173 

soiled clothing saturated with grease and perspiration. Epidemics 
of furuuculosis have, however, occurred where the origin was due 
not to contagion, but to a mycelium swallowed with certain 
vegetable substances used as food. It was assumed bv Senner that 
the fungus was conveyed from the intestine into the blood and 
thence to the skin, as he found threads of the growth in the 
sloughs cast off from the pus-cavity. This theory would ascribe, 
in certain cases, the origin of boils to embolism. Among the 
predisposing causes of boils may be mentioned either the lack of 
cleanliness of the skin or the excessive use of baths or douches, 
the presence of organic disease elsewhere, as diabetes, or any 
lowered state of vitality, as anaemia. 

The first symptom of a boil is the appearance of a minute 
papule situated at the opening of a hair-follicle. Its presence is 
first noticed through an itching sensation which it causes, there 
being but slight pain at the time. At first it seems as if the 
inflamed spot was quite superficial, and that nothing more formid- 
able than an acute pustule would develop. The infiltration of the 
skin soon becomes more extensive and deeper, and a removal of 
the projecting hair in no way arrests the inflammatory process. 

A small crust forms on the surface of the swelling, and from 
time to time a minute quantity of pus exudes. If at the end of 
two or three days the scale is removed, a very fine probe can be 
introduced for about half an inch into the inflamed mass, and it is 
now quite evident that the suppuration lies much more deeply 
than was at first apparent. On palpation the infiltration is found 
to extend into the subcutaneous tissue, and the swelling may have 
increased to the size of a pigeon's or a hen's egg. 

The pain is usually severe on pressure, and there is always the 
proverbial soreness associated with this affection. When the boil 
begins to discharge freely close inspection reveals the presence of 
a small round opening that extends downward to a pus-cavity con- 
taining the slough or "core," which at the end of a week or ten 
days is usually discharged spontaneously. The opening, which has 
been considerably distended by the passage of the contents of the 
cavity, now contracts and the minute abscess heals by granulation. 
The furuncle developing in the sudoriparous glands is less common: 
it is more readily recognized on surfaces where there is no hair, as 
the palm of the hand. It begins with a deep-seated, pulsating pain 
and a feeling of tension. Sometimes the process seems to be devel- 
oping beneath the skin. In the cheek it may be felt as a tumor 
situated between the mucous membrane and the skin. In infants 



174 SURGICAL PATHOLOGY AND THERAPEUTICS. 

and in young children such boils may be found on the thighs and 
in parts soiled by urine and fecal matter. Boils may sometimes be 
complicated by lymphangitis. 

Furunculosis is a term applied to those cases where the patient 
is afflicted with a succession of boils, which appear to come out in 
crops. The contagion having once been disseminated thoroughly 
on a susceptible subject, it is a difficult task to destroy the virus or 
to so change the conditions that the micro-organism will no longer 
accumulate at certain points. This tendency may continue, not- 
withstanding treatment, for a year or more in extreme cases. 

The prophylactic treatment of boils is of great importance. 
Individuals with a tendency to acne or to furunculosis should be 
careful to keep their skin well washed and should frequently 
change their underclothing. Special attention should be given 
to disinfection of the nails, and such patients should be cautioned 
against frequent scratching. When the boil begins to form and is 
quite superficially situated abortive treatment should be attempted. 
The simplest and most effective method to abort a boil is to apply 
with a glass rod or a stick the liquefied crystals of carbolic acid. 
Equal parts of carbolic acid and tincture of iodine may be applied 
in the same way. When the process is further advanced, parenchy- 
matous injections of a 3 per cent, solution of carbolic acid may be 
given with a subcutaneous syringe. In small furuncles only a few 
drops should be injected; in larger boils nearly a whole syringeful 
may be necessary. This method is uncertain and painful. A more 
effective method is to lay the inflamed area open by a crucial incis- 
ion. In the early stages this operation most effectively arrests fur- 
ther development of the furuncle. It is, however, not applicable 
to exposed parts where it is desirable to avoid a scar. 

The fully-developed boil may be treated by incision and curet- 
ting the interior in order to remove the necrosed tissue and the 
bacteria. This operation should be rendered painless by subcuta- 
neous injection of a 2 per cent, solution of cocaine. The wound 
should be cleansed with peroxide of hydrogen and filled with a 
drying powder, such as iodoform, aristol, or dermatol, and be 
dressed with iodoform or with aseptic gauze. The dressing can be 
retained with a little cotton soaked in collodion, and can usually 
be allowed to remain undisturbed for two or three days. 

When it is desirable to avoid a scar, the furuncle should be 
dressed with an antiseptic poultice and the minute pus-cavity be 
syringed out daily with a weak solution of some antiseptic. In 
performing this little operation care should be taken not to over- 



INFECT1 1 'E INFLAMM. I WON. 175 

distend the pus-cavity, or the septic process may be made to spread 
and all the symptoms be aggravated. 

When the boil has discharged its core, it may be dressed with 
cotton held in place by collodion. This dressing is usually the 
most comfortable in such regions as the neck or the face or the 
trunk. It possesses the great advantage of establishing an isolation 
of the boil, so that its secretion cannot contaminate the adjacent 
hair-follicles. Great care should be taken to keep the surrounding 
skin in as aseptic a condition as possible, and frequent antiseptic 
washings should be performed. As a prophylactic measure in case 
of furunculosis antiseptic baths may be employed. An ounce of 
sulpho-naphthol in an ordinary bath-tub of warm water furnishes a 
bath sufficiently antiseptic to remove from the epidermis any excess 
of bacteria which may there exist. 

A great variety of internal treatment has been recommended. 
The sulphide of calcium is supposed to possess unusual virtues, and 
is given in doses of -J- gr. three or four times a day. The writer has 
never seen any satisfactory results from its use. The employment 
of tonics and nourishing diet, and placing the patient in suitable 
surroundings, favor such a condition of the system as will enable 
it to resist a further invasion of the pyogenic bacteria. 

Carbuncle is a suppurative and gangrenous inflammation of the 
skin and the subcutaneous cellular tissue, and begins, like furuncle, 
on the surface of the skin, but the inflammation spreads downward 
much deeper into the adjacent structures. The organisms most 
frequently found in carbuncular pus are the staphylococcus pyogenes 
aureus and albus. They may be inoculated by the finger-nail in 
scratching or through small injuries inflicted by the clothing, as 
the edge of a collar, or through minute blisters. A state of gen- 
eral debility places the tissues in a condition to furnish a favorable 
soil for the growth of the bacteria. Certain constitutional diseases, 
such as diabetes, seem frequently to be accompanied by carbuncle. 
Carbuncle is rarely seen in childhood. It is most frequently ob- 
served in persons over forty years of age. A carbuncle is usually 
situated in the neck and the back, although carbuncular inflamma- 
tions are occasionally seen upon the face and upon other portions 
of the body. The term ' ' carbuncular inflammation ' ' is usually 
employed to convey the idea of a suppurative process developing 
in a series of separate small foci of pus, and spreading in this way 
through tissues without any very well defined limits. This appli- 
cation of the term is due to the peculiar appearance of a carbuncle, 
which seems to develop simultaneously from a number of independ- 



176 



SURGICAL PATHOLOGY AXD THERAPEUTICS. 



ent foci. Such, however, is not the case, as the affection begins in 
very much the same way as a boil, and differs from it chiefly in 
involving a very much larger area. 

The disease begins as a minute papule on the surface of the 
skin, which usually burns and itches acutely, and the papule may 
be mistaken for the bite of an insect. It is due to this fact, prob- 
ablv, that flies have often popularly been supposed to be the car- 
riers of the contagion. From this superficial point the area of 
inflammation gradually enlarges downward and laterally, so that 
a wedge-shaped portion of the integument becomes involved in the 
process. When the infection has reached the subcutaneous cellu- 
lar tissue the disease spreads laterally, the dense fascia covering the 
muscle preventing deeper infection. Cases are on record, however, 
where the muscles of the back have become involved in the sup- 
purative process, but these cases are rare. 

A glance at the anatomy of that portion of the skin where car- 
buncle most frequently occurs — namely, that of the upper dorsal 
region — will serve to explain many of the striking peculiarities of 
this affection. The skin in this region is extremely thick, prob- 
ably thicker than at any other portion of the body. It forms a mass 
of dense fibrous tissue well calculated to sustain burdens or to pro- 
tect a comparatively defenceless portion of the body. The great bulk 

of the cutis vera necessitates cer- 
tain important modifications of 
contained and contiguous struc- 
tures. The hair-follicles, being 
those supporting downy hair only, 
and therefore shallow, project 
downward but a short distance 
into the uppermost layers of this 
mass of fibre, and there would be 
no communication with the sub- 
cutaneous adipose tissue were it 
not for oblique columns of fatty 
tissue which extend upward from 
below. These fat-columns, or 
columns adiposes, which are 
found beneath each hair-follicle, 
are of about the same width as 
the hair-follicle — perhaps a little 
broader — and they contain, besides loose connective-tissue, fat-cells, 
and vessels, the coil of a sweat-gland suspended midway in the 




-Columna Adiposa. 



INFECTIVE INFLAMMATION. 177 

shaft (Fig. 33). There are generally two horizontal branches 
to this cleft in the skin, and the writer has shown elsewhere how 
an injection-mass forced in from below may ramify through the 
whole thickness of the cutis, forming a quite delicate network and 
marking out the anastomosing system of lymphatic channels. At 
the point where these columns open into the parts immediately 
below this dense sheet of cutis is found a broad band of fibrous 
tissue given off from one side and extending obliquely down 
into the subcutaneous structures, finally to be attached (tendon-like) 
to the fascia, beneath which lie the muscles. These fibrous bands, 
which interlace in various directions, are very different from the 
delicate ''cellular tissue" underlying other portions of the skin, 
and form a dense network that holds firmly in place the tough hide 
to which it is attached. In the interstices there is the usual 
loose connective tissue, which, is largely occupied by fat-cells. 
Students during their dissections become familiar with the tough- 
ness of this subcutaneous layer, as does also any surgeon who has 
once attacked a lipoma in this region with the vain hope that it 
was going to enucleate easily. It will be observed that the alve- 
oli formed in the meshwork, although having a comparatively lim- 
ited commuuication with the neighboring subcutaneous structures, 
have a tolerably direct, though narrow, medium of communication 
with the surface through the fat-columns, which, chimney-like, 
are placed directly above the alveoli. 

The characteristic features of the carbuncular swelling, when 
fully developed, are its broad, flat base, with an oval or a flattened 
surface raised considerably above the level of the skin. The out- 
line of the tumor is usually circular. The skin is reddened and 
perforated at several points with holes of considerable size from 
which pus oozes. A more careful inspection discloses the existence 
of a large number of minute pustules dotted over the surface of the 
tumor. The skin is extremely tense and red, and the infiltrated 
parts have a density unusual in ordinary inflamed tissues. Later, 
the central portion of the skin is gradually destroyed by the enlarge- 
ment of the various openings, which fuse together and leave an 
open crater. The deeper tissues thus exposed appear to be honey- 
combed with numerous purulent deposits. These peculiar appear- 
ances are readily explained by the anatomical structure of the part. 

When the deeper tissues become infected and suppurate the pus 

naturally endeavors to seek an outlet. It cannot spread laterally 

as easily as in other portions of the body, as the skin is held down 

firmly on the fascia by the fibrous bands already described. The 

12 



i 7 8 



SURGICAL PATHOLOGY AND THERAPEUTICS. 



dense cutis vera also does not yield to the pressure from below. 
The virus and the pus therefore work from one interspace to 
another, and thus gradually infiltrate the deep tissues. The pus 




Fig. 34. — Infiltration of Columna Adiposa and Subcutaneous Tissue with Pus in Carbuncle. 



also makes its way to the surface through points of least resist- 
ance, these points being the columnar adiposse (Fig. 34). These 
chimney-like spaces allow a considerable quantity of pus to come 
to the surface, and where it escapes around the edges of the lanugo 
hair one of the larger openings is formed. The pus also spreads 




Fig. 35. — Diagram of a Carbuncle. 

laterally from the column through the lymphatic spaces of the 
skin, and finally reaches the papillary layers through the perivas- 
cular lymph-sheaths. Many of the papillae become distended with 
pus, and thus are formed the smaller pustules. 



INFECT1 1 '/•; INFL . I MM A TION. 1 79 

The infiltration and disintegration of the tissues are so complete 
and the coagulation-necrosis is so extensive that large sloughs form. 
The centre of the carbuncle thus becomes an open crater, and the 
dense fibrous meshes of the subcutaneous tissues which constitute 
the base of the crater are eventually thrown off as sloughs (Fig. 
35). As pus accumulates one or more cavities of considerable size 
form if the skin has not sufficiently melted away to allow of its 
escape. 

Carbuncles may vary greatly in size. A carbuncle is usually 
from 2 to 3 inches in diameter, about the size of a mandarin orange, 
but occasionally it may attain an enormous size. It reaches its full 
development, in the larger varieties, about the end of the second 
week, and the final healing of the wound, after the sloughs have 
been cast off, may not be reached for five or six weeks or even 
longer. 

As already stated, the disease does not penetrate the deep fascia, 
but instances are known in which the suppuration invaded the 
intermuscular spaces, and Monnier describes a case in which the 
pus penetrated the spinal canal and caused death from meningitis. 
In the beginning the parts are painful, but, as the swelling forms 
slowly, little pain may be experienced by the patient during the 
further progress of the disease. Paget relates the case of a lady, 
having a good-sized carbuncle on the back of her neck, who was 
able to go through with the duties and pleasures of a London 
season with the carbuncle concealed beneath her hair worn low 
behind. 

The constitutional condition of the patient varies greatly. In 
the milder cases there may be little or no fever, but large carbun- 
cles are usually associated with considerable cachexia, and the con- 
dition of the patient at times becomes critical. The prognosis of 
the disease is unfavorable when associated with diabetes or when it 
occurs in persons of advanced years. 

Sloughing of the affected tissues is a pronounced feature of car- 
buncle, and it gives rise to a great loss of substance. Occasionally 
this process may assume a gangrenous type, and a tendency of the 
gangrene to spread may become a feature of the case. The writer 
has seen the entire carbuncle slouch awav and the ofanorene involve 
a considerable area of the surrounding skin and tissues. 

The term "carbuncle" is given to an affection of the upper 
lip, although most of the characteristic features of a carbuncle 
are wanting. This is due to the anatomical nature of the part, 
which differs greatly from the skin of the back. It is, however, 



180 SURGICAL PATHOLOGY AND THERAPEUTICS. 

like carbuncle, a deep-seated inflammation involving the skin and 
the subcutaneous tissue. It is usually accompanied by profound 
constitutional disturbance, and in many cases the prognosis is most 
unfavorable. This condition is due to the involvement of the rich 
venous anastomosis with the cerebral sinuses. Thrombosis of the 
facial vein is a frequent complication, and the suppurative phlebitis 
may involve the ophthalmic vein, the middle meningeal vein, and 
may even extend downward to the jugular vein. Death may occur 
both as a result of meningitis and of pyaemia. 

The treatment of carbuncle has varied -a great deal during the 
writer's professional experience. Formerly it was the custom to 
make several crucial incisions through the tumor, thus laving- 
open all its recesses, and then to apply a flaxseed poultice to favor 
a separation of the sloughs. In cachectic subjects this treatment 
was often followed by an aggravation of the constitutional symp- 
toms and an extension of the suppuration into the healthy tissues, 
which were exposed by an unnecessary prolongation of the 
incisions. A reaction followed this treatment, and one author 
advised expectant treatment, the sloughs being allowed to suppu- 
rate and discharge themselves at leisure. 

At the present time the antiseptic treatment has displaced all 
others. The extent to which antiseptic measures may be carried 
varies. In milder forms of carbuncle or in subjects who are too 
feeble to stand any operative measures an antiseptic poultice of 
cotton, dipped in a weak solution of carbolic acid (i : 200), may be 
applied, and such cavities as can easily be reached should be 
syringed out with an antiseptic wash. The poultice should be 
renewed frequently, and the surrounding tissue should be washed 
once or twice daily with a solution of corrosive sublimate (1 : 3000) 
to protect the sound skin from infection by the pus which is 
constantly poured over it. 

The more radical treatment of removal of the infected tissues is 
the one that should be employed in the majority of cases. This 
consists in laying open the carbuncle by crucial incision after 
preliminary cleansing of the parts, and by thorough removal of 
the infiltrated parts beneath. This may be done with the curette, 
with the scissors, or the knife. All infected areas should be 
excised if possible. In small carbuncles this operation may be 
performed without pain if the surrounding skin is injected with a 
2 per cent, solution of cocaine. The skin may also be removed 
partially if much infiltrated. Bleeding vessels should be tied if 
necessary, the parts should freely be dusted with iodoform or 



INFECTIVE INFLAMMATION. 181 

washed with peroxide of hydrogen, and the wound be filled with 
iodoform gauze. Considerable relief from the pain follows this 
operation, and at the next dressing, which may not be performed 
for two or three days, the inflammation will have largely disap- 
peared. 

In some cases a condition somewhat resembling hospital gan- 
grene prevails: the skin is destroyed and the parts beneath are 
covered with extensive sloughs. The edges of this crater are red- 
dened and infiltrated, and frequently undermined by the gangrene. 
The circulation appears to be too feeble to furnish sufficient fluid 
to throw off the sloughs. Under these circumstances the patient 
should be etherized and the gangrenous tissue should be removed 
with a sharp spoon or with scissors, and the edges of the wound 
should fully be laid open by incisions through the skin. The 
thermo-cautery should then be applied over the whole infected 
surface. 

The most radical treatment consists in total excision of the 
carbuncle. This operation has been advised in cases of severe 
constitutional disturbance when the strength of the patient is 
insufficient to produce any healthy reaction at the seat of the 
disease, or in old people in the early stages of the disease when 
it is desired to spare them the dangers of septic infection. A 
circular incision should be made around the edge of the infected 
portion of the skin, and all diseased tissue should rapidly be 
removed. As this method involves a considerable loss of blood, 
it would be preferable to make the skin incisions only with the 
knife and to finish the operation with the actual cautery, or to 
perform the whole operation with the cautery knife, which may 
be done without the loss of a drop of blood. The effect of the 
removal of such a source of contagion is immediate. The fever 
and delirium disappear, the pain is greatly relieved, and the 
patient obtains refreshing sleep. 

Carbuncle of the lip may occasionally run a mild course, but 
in a typical case the symptoms are very grave, and the treatment 
should be prompt and heroic. It is not sufficient to content one's 
self with one or more incisions. The infected area should be 
extirpated. Winiwarter reports two cases in which he approached 
the carbuncle through the mucous membrane, and, having excised 
all diseased tissue, filled the cavity thus made with iodoform 
gauze. These cases made a good recovery without visible scars. 

In the severer form of carbuncle the constitutional disturbance 
needs careful attention. The patients, who are frequently aged 



182 SURGICAL PATHOLOGY AND THERAPEUTICS. 

and infirm subjects, should be confined to the bed. The diet 
should be digestible and highly nutritious, and should be given in 
small quantities at frequent intervals. Alcohol should be admin- 
istered with a free hand, but the patient should be watched to see 
if the use of stimulants causes flushing. Opium in some form 
may be needed to relieve pain and ensure repose, and if the heart's 
action be feeble digitalis may be given in moderate doses. The 
chief reliance in these cases should be, however, on nourishing 
diet and alcoholic stimulants. 

4. Ulcer. 

An ulcer is a solution in continuity of the skin or the mucous 
membrane which shows no tendency to heal. An ulcer has been 
defined as molecular death of the part: it owes its existence, in 
fact, to an excess in action of the retrograde changes over those of 
repair. In this respect it differs from an open granulating wound, 
which possesses a tendency to heal. The latter may, however, 
become an ulcer at any time if the granulations begin to break 
down. The process is closely allied to that known as necrosis or 
gangrene. 

Ulcers are classified at the present time chiefly according to 
their mode of origin. A large number of ulcers result from infec- 
tious disease, such as syphilis, tubercle, leprosy, and glanders; 
perhaps, also, cancer. The non-infectious ulcers are preceded and 
accompanied by a chronic inflammatory process in the tissues in 
which they develop. The loss of substance may be the result of 
the inflammatory process, or it may be the primary condition 
around which the chronic inflammation has developed itself. 
Among the local causes for the development of an ulcer is the 
tendency to degenerative processes in the inflamed tissue or 
impairment of the circulation. Thus, a local anaemia may be 
produced as the result of obliterative changes in the walls of 
arteries or impairment of the venous circulation. Trophic disturb- 
ances may be caused by an impairment of the innervation of a 
certain portion of the body. Local irritation, with breaking down 
of tissue, may be caused by friction or by pressure. Mechanical 
obstacles to the healing of a wound must also be regarded as a 
cause of ulcer. 

The anatomical characteristics of an ulcer are determined by the 
nature of the ulcerated surface and its margins. The ulcerated 
surface presents a great variety of conditions according to the 
influences to which it has been subjected. In freshly-formed 



INFECTIVE INFL. l.U.U. I TION. 



183 



ulcers there is an inflammatory exudation mingled with fragments 

of broken-down tissue or tissue in a state of coagulation-necrosis. 
Beneath this tissue lies a layer of cells forming what is known as 
granulation tissue. The cells of which this layer is composed are 
largely polynucleated leucocytes and epithelioid cells, with com- 
paratively little intercellular substance. A rich capillary network 
of blood-vessels runs through this tissue and sends branches 
toward the surface. The tissue underlying this somewhat super- 
ficial layer of cells contains a greater quantity of intercellular sub- 
stance or many fusiform cells. Often this tissue is made up 
largely of an cedematous fibrous tissue with small clusters of cells 
considerable distances apart. Below this there is usually found 
some of the fibrous tissues of the deep layers of the skin. The 
granulation tissue is soft and succulent, and may easily be scraped 
away with a curette. The tissue below T is much denser, and 
appears as a white fibrous layer w 7 hich shuts off the granulations 
from the surrounding healthy tissues. 

The edges of the ulcer consist of the surrounding skin, which 
has been more or less altered by inflammatory changes. There is 
usually some thickening of the skin, which is consequently raised 




Si ■• 






..*•■- 









. _~~~ ■ • 









Fig. 36. — Ulcer of Leg. 



above the surface of the ulcer. The papillae are in these cases 
somewhat hypertrophied. In and below them we find numerous 
leucocytes and epithelioid and fusiform cells in various stages of 
development. In the deeper layers of the rete mucosum and in 



1 84 SURGICAL PATHOLOGY AND THERAPEUTICS. 

the papillary layers of the skin in old ulcers masses of blood- 
pigment are seen (Fig. 36). The margins of the ulcer are fre- 
quently on a level with the ulcerated surface; sometimes they are 
undermined by the granulation tissue. Under these circumstances 
the skin is red and infiltrated, and often has a bluish tinge, due to 
the feeble nature of the circulation. The borders of the ulcer 
may become firmly adherent to the deeper parts, particularly bone 
or periosteum. 

The non-infective ulcers are classified according to their mode 
of origin or according to certain characteristic peculiarities they 
possess. Among the numerous varieties described in medical 
literature may be mentioned the inflammatory ulcer, the callous or 
atonic ulcer, the varicose ulcer, the neuroparalytic or perforating 
ulcer, the phagedenic or gangrenous ulcer, and the erethistic or 
irritable ulcer. 

The inflammatory ulcer is caused by bruising or friction of a 
part, and is traumatic in origin. Inflammatory ulcers are more 
frequently seen upon the legs, as the persistence of the ulcer is due 
to the mechanical condition of the circulation, which favors a 
stagnation of the blood in the part, in consequence of which 
the efforts at repair are more feeble. These ulcers may also be 
caused by burns or by frost-bites or by the action of chemical 
substances. 

The commonest form of ulcer seen by the surgeon is the vari- 
cose ulcer, which is situated on the shin, usually at the junction of 
the middle and lower thirds. Its origin is readily recognized in 
most cases by the varicose veins seen running beneath it and from 
its upper margins to the inner border of the popliteal space. The 
cause of the ulceration is a passive hypersemia, in consequence of 
which stagnation of the blood takes place in the smaller veins and 
capillaries, and the surrounding tissues become saturated with a 
thin serum which oozes through their walls. This is the cause of 
the oedema which, in a greater or lesser degree, accompanies the 
disease. With the serum there is an exudation of red corpuscles, 
producing an extensive pigmentation of the skin, which usually 
precedes or accompanies the stage of ulceration. The nutrition 
of the part being thus enfeebled, a slight blow will cause an 
abrasion of the epidermis, and the minute wound thus made will 
gradually develop into an ulcer of considerable size, or a minute 
slough may be caused by a thrombosis of one of the small super- 
ficial veins. With the formation of a wound infection takes place 
by bacteria invading the exposed surfaces, and the element of 



INFECTIVE INFLAMMATION. 185 

inflammation is thus introduced. The surrounding parts are now 
infiltrated with leucocytes, and are further softened by a continua- 
tion of the inflammatory process. In neglected ulcers the amount 
of inflammation may be great and the limb may become swollen, 
tense, and excessively painful. Phlebitis may occasionally become 
a complication of the process. 

Ulceration from pressure may occur in a manner somewhat 
similar to that by which decubitus or bed-sore is produced. It 
differs, however, from decubitus in the absence of a slough. The 
principal seat of these ulcers is in the sole of the foot, although 
they may be found on prominent spots about the inferior extrem- 
ities as the result of pressure from splints. The pressure is not 
severe enough to produce stasis and death of the part, but as the 
result of continuous pressure the epidermis thickens and a callos- 
ity forms, which, acting as a foreign body, produces friction upon 
the true skin below, causing inflammation; eventually suppuration 
takes place beneath the thickened mass of epidermis. A small 
ulcer is thus developed, which is surrounded by raised edges 
consisting of a greatly hypertrophied layer of epidermis. The 
rigidity of the parts and the low vitality of the tissues at the base 
of the ulcer prevent cicatrization. 

Ulcers are particularly liable to develop in paralyzed parts. 
They may be caused by inflammatory processes which readily 
occur in such localities or as the result of pressure. The insen- 
sibility of the skin and the lack of muscular action allow pressure 
to remain constant on a given spot. Absence of muscular contrac- 
tion also favors a stagnation of the venous blood in the tissues, 
which predisposes to ulceration. 

The so-called mal perforant, which occurs upon the sole of the 
foot, appears as a sharply-cut circular ulcer with surrounding 
thickened edges, often almost completely shut in by the overhang- 
ing borders of epidermis. It is found most frequently beneath the 
metatarso-phalangeal articulation of the great toe, but may be 
found on any part of the sole of the foot which is subjected to the 
most pressure in any particular case. This form of ulcer has been 
supposed to be associated with disturbances of nutrition in the 
nervous system. These disturbances may be due to a local affec- 
tion of the peripheral nerves, accompanied with inflammatory or 
degenerative changes, or to some central lesion. It has been found 
frequently associated with locomotor ataxia. This supposed 
association with certain trophic nerve-disturbances owes its origin 
partly to the fact that the borders of the ulcer are anaesthetic. A 



1 86 SURGICAL PATHOLOGY AND THERAPEUTICS. 

pin may be introduced for some distance into the adjacent skin 
without causing pain. According to Winiwarter, the nerve lesion 
is not the direct cause of these ulcers, the exciting cause being the 
local irritation produced by pressure or by friction. No distinction 
should be made between those of a neurotic and those of a non- 
neurotic origin. It is, in fact, an ulcer due to pressure such as has 
already been described. 

A microscopical examination of a perforating ulcer shows in the 
ulcerating surface masses of hyaline material enclosing red blood- 
corpuscles and molecular detritus, and very few cells. The sur- 
rounding skin is much sclerosed and the papillae are usually 
hypertrophied, and above them are piled up enormous layers of 
epidermis. 

If pressure is continued for a long time upon the ulcer, the 
inflammation and suppuration spread, and the adjacent joint of a 
toe may become involved, and necrosis of the bone may result. 
This process is not to be mistaken for senile ulceration or gan- 
grene, which is found upon the toes and foot, though usually not 
on the plantar surface. 

French surgeons recommend amputation for mal perforant, and 
the writer has seen several cases treated in this way. Usually, 
however, rest in bed with local treatment by antiseptic poultices 
suffices to heal the ulcer. Careful removal of the rigid margins 
and curetting the indolent surface of the ulcer will place it in a 
condition favorable for repair. 

Similar ulcers are sometimes seen upon the feet of patients 
afflicted with anaesthetic leprosy, and are in such cases probably 
— in part at least — of bacterial origin. The writer amputated the 
foot of a patient for this disease. The foot was misshapen and 
greatly clubbed, and upon the most dependent point an ulcer 
existed which seemed largely due to pressure. 

Ulcers may be classified according to certain changes or compli- 
cations which occur during their existence. An inflamed ulcer is 
one in which the base and surrounding parts are more or less 
acutely inflamed. The ulcerated surface is intensely red, bleeds 
easily, and secretes pus freely. It may be at times covered with 
sloughs or croupous membrane. The borders are swollen, and the 
surrounding skin is often tense and shiny and excessively tender. 
These conditions are caused by neglect, by application of irritating 
substances, or by contact with acrid secretions. Ulcers in this 
condition often become very painful. 

Erethistic ulcer is one in which great sensitiveness persists and 



INFECTIVE INFLAMMATION. 187 

is hard to relieve. The ulcerated surface lias the appearance of a 
tissue which is not in an active state of repair. There is no tend- 
ency of the edges to cicatrize: they present rather the appearance 
of being bitten out. The slightest touch is often excruciatingly 
painful. Painful ulcers are often found in the neighborhood of 
very sensitive parts, as the anus. The cause of the great sensitive- 
ness has been ascribed to an unusual thinness of the granulation tis- 
sue. It is often due to pronounced anaemia following loss of blood 
or to severe disease, and disappears with a return to the normal con- 
dition of nutrition (Winiwarter). 

The fungous ulcer is caused by an excessive growth of granula- 
tions. This growth is due to an abundant blood-supply without 
any disposition on the part of the edges to approximate themselves. 
They are found upon very vascular parts where the epidermis is 
thick, as on the hands and the feet. Such a condition of the gran- 
ulation is popularly known as ' ' proud flesh, ' ' which is supposed to 
be an obstacle to the healing process. It often happens in wounds 
of the hands or of the feet that a luxuriant growth of granulations 
will form a little tumor projecting above the somewhat rigid edges 
of the skin. The epidermis pushes its way into the granulations 
and a mushroom-like tumor is formed with a small pedicle. If the 
tumor is cut off, an arteriole of considerable size is found around 
which new tissue is rapidly formed, and the tumor grows again 
before the sluggish epidermis succeeds in closing the wound. Such 
granulation tumors must be shaved off even with the surface, and 
the small opening left should be cauterized with a stick of nitrate 
of silver, so as to destroy the nutrient artery. Compression should 
then be applied and the ulcer will readily heal. Fungous granula- 
tions often protrude from the mouths of fistulae, particularly those 
leading to tuberculous abscesses or to a foreign body. 

Hemorrhagic ulcers are most frequently seen in scurvy. The 
ulcerated surface is a livid blue, and the granulations readily break 
down. A vicarious hemorrhage is sometimes seen in cases in which 
there has been a suppression of the menses or an arrest of bleeding 
from hemorrhoids (Winiwarter). 

Torpid ulcers are seen in individuals suffering from the cachexia 
of an acute or a chronic disease, in consequence of which there is 
a diminished blood-supply to the part. The granulations are pale 
and the secretion is thin and watery. 

A callous ulcer is one which has existed without material change 
in size for a long period. The surface is dirty and it secretes a 
thin muco-purulent material. The edges are raised considerably 



188 SURGICAL PATHOLOGY AND THERAPEUTICS. 

above the surface, and the skin for some distance around is indu- 
rated and immovable. Old varicose ulcers often present this type. 

Phagedenic ulcers are those which spread rapidly with symptoms 
of great local irritation. They are seen in epidemics of gangrene 
or in ulcers which have been treated by irritating applications. A 
chancre may occasionally become phagedenic, and when in this 
condition it is an unusually obstinate affection. Antiseptic lotions 
and the application of iodoform in powder, with tonic treatment, 
will usually arrest the process. If the miserable, broken-down 
individuals who are usually the subjects of this form of ulcer can 
be placed in favorable surroundings, the disease will readily yield 
to treatment. 

The treatment of ulcers in general consists primarily in the ele- 
vation of the part, so that the circulation, which is an important 
factor in their development, may properly be regulated. The pas- 
sive hyperaemia which exists, particularly in the case of varicose 
veins, must be relieved, in order that the parts may return to their 
natural condition and that they may thus be enabled to carry on 
the process of repair. A neglected ulcer is usually in a very foul 
condition, owing to the decomposition of pus and sloughs confined 
beneath scabs and to the presence of macerated epidermis contain- 
ing a great variety of bacteria. 

An antiseptic poultice of carbolic acid or of phenyl (i : 250), 
applied to the limb after the patient has been placed in a bed, 
usually suffices, with frequent antiseptic washings, to remove all 
odor in a few days: the poultice eventually cleans the wound thor- 
oughly and enables the parts to throw out healthy granulations. 
Among cleansing washes may be mentioned peroxide of hydrogen, 
weak solutions of permanganate of potash of a strength slightly 
to redden water, chlorinated soda, and carbolic acid, all of which 
owe their virtue in part to their ability to penetrate greasy sub- 
stances. A weak wash of tincture of iodine may also be used to 
advantage, particularly if there is any reason to suspect the pres- 
ence of tubercle. If it is desired to apply a dry dressing, iodo- 
form or aristol may be used if the odor is strong. Dermatol pow- 
der has a soothing effect, and has the advantage of being odorless. 
In mild types of ulcer pure zinc ointment is a useful dressing, as it 
forms a protective layer which cannot easily be removed. 

Erethistic or painful ulcers are usually not amenable to any 
form of dressing. Poultices are complained of bitterly as heating 
and " drawing." A perfectly neutral material, like vaseline, 
answers best on such ulcers. An ointment composed of hydro- 



INFECTIVE INFLAMMATION. 189 

chlorate of cocaine, 12 grains to the ounce, applied once daily, 
gave great relief in the writer's experience. A protective of 
gntta-percha tissue is often superior to any other dressing in cases 
of erethistic ulcers. 

Indolent ulcers are often stimulated by the application of 
balsam of copaiba or balsam of Pern on charpie. Tincture of 
myrrh, 1 drachm to the ounce of water, applied on charpie, has a 
very tonic effect upon the granulations. The patient should be 
encouraged in cases of ulcers of the lower extremities to keep the 
limb elevated. If possible, he should remain in bed, and he 
should be impressed with the importance of absolute rest to the 
part. 

When it is necessary to treat the case as an ambulating one, the 
passive hypersemia may be relieved by pressure by bandage or by 
adhesive plaster. The ulcer should then be strapped with narrow 
overlapping strips of diachylon or with rubber plaster. A flannel 
bandage, cut bias and about 4 inches wide, should then be applied 
from the toes to the knee. The plaster may be allowed to remain 
two or three days ; the pus which collects beneath the plaster dur- 
ing this time is, in favorable cases, of an unirritating character 
and serves the purposes of a moist dressing. The rubber bandage 
can be used successfully for the same purpose, as rubber is usually 
unirritating to granulating surfaces. The patient may be in- 
structed in its application, and the bandage may be removed once 
or twice daily for the purpose of washing the ulcerated surface. 
The rubber bandage is, however, an uncomfortable and inelegant 
mode of treatment, being suitable only for laboring people who 
cannot spare the time for more elaborate treatment. 

Many ulcers owe their inability to heal to the firm adhesion of 
the surrounding skin to the parts beneath. Much benefit has been 
obtained by lateral incisions, which release the edges of the ulcer 
and allow cicatrization to go on. By far the most effective of 
operative procedures is skin-grafting after the method of Thiersch. 
This operation is so simple that it can readily be performed by any 
practitioner. It consists in the removal of the granulating surface 
by scraping with a curette or by shaving with an amputating 
knife. The parts should be washed thoroughly, and all antisep- 
tic agents should be removed with boiled water or with a steril- 
ized salt solution, .6 per cent. Thin shavings of skin should be 
removed from the thigh of the patient, the parts having also been 
carefully washed beforehand. The portions removed should be 
about 1 inch in width and from 2 to 6 inches in leneth. Thev 



190 SURGICAL PATHOLOGY AND THERAPEUTICS. 

should be so laid upon the re-freshened surface of the ulcer as to 
overlap one another slightly, and should extend a short distance 
beyond the margin of the wound. Thin strips of gutta-percha 
tissue or of thin rubber should be laid over grafts, and an aseptic 
dressing should then be applied. The dressing should be renewed 
in about three days. If the grafts have adhered, they will be 
found to have a slightly pinkish tinge. Too long use of the 
rubber tissue, owing to the macerating influence, endangers the 
life of the grafts. 

Small ulcers may be grafted in this way without etherization. 
In such cases a subcutaneous injection of cocaine will be needed to 
produce local anaesthesia. In large ulcers great attention to all 
details is needed to ensure success, but in small ulcers the opera- 
tion may be performed successfully without any elaborate prepara- 
tions. In the case of ulcer upon the leg the patient should not be 
allowed to walk for several weeks after the operation, as the cica- 
tricial tissue will break down and the ulcer will reappear if the 
limb is placed in a dependent position at too early a date. 

5. Fistula. 

A fistula may be defined as an abnormal opening into a normal 
cavity or organ or as a long, narrow channel indisposed to heal. 
In the former case the wound may have healed, but the hole 
remains, through which the normal secretions escape. A fistula 
which communicates with a suppurating cavity resembles in its 
nature an ulcer, and like that affection may be the result of the 
failure of an abscess to heal. It is, in fact, a cylindrical ulcer, 
and its walls resemble, histologically, the surface of an ulcer. It 
is surrounded by a mass of more or less indurated and inflamed 
tissue, and its surface consists of a layer of granulation tissue 
which shows all the varieties of appearance seen in ulcers. 

A fistula may be caused by the anatomical relations of the part 
or by the peculiar shape of the wound or abscess-cavity. It may 
be due to the escape of physiological secretions or excretions, such 
as saliva or faeces, and it may also be due to the presence of a 
foreign body or a sequestrum or fragment of sloughing tendon. 

After laparotomy or extirpation of a tumor, like that of the 
thyroid gland, where numerous ligatures are used, a fistulous 
opening frequently remains, leading to a ligature which has not 
been enclosed in the cicatricial tissue. 

When pus has burrowed for a considerable distance beneath the 
skin, and a long and narrow granulating surface has been estab- 



INFECTIVE INFLAMMATION. 191 

lished, the mere shape of the cavity is in itself an obstacle to 
cicatrization, as the secretions have no opportunity to escape. 
The presence of a specific virus like that of tubercle or cancer is 
also an adequate cause for the permanence of a fistulous opening. 

The treatment of the fistulous ulcer consists in laying it open, 
so that it may be converted into a wound with a wide opening that 
may heal from the bottom, or in the removal of the foreign body 
which prevents cicatrization, or in the application of medicated 
substances to its inner surface. 

When a fistula is surrounded by inflamed and indurated tissue 
the condition is usually due to contained secretions which have 
been prevented from escaping by imperfect efforts at cicatriza- 
tion. In such cases poultices or soothing applications should be 
employed to allay all irritation before any attempt is made to favor 
repair. 

The fistulous opening must then be enlarged, and the canal 
must be made, if possible, an open wound, to which a dressing may 
be applied throughout its whole surface. All foreign bodies must 
of course be removed, and secretions of pus be allowed full vent. 
Sinuses which run subcutaneously should be laid open freely and 
the various ramifications followed to their extremities. The sur- 
face of the fistula should then be curetted thoroughly, so that 
healthy granulations ma} 7 replace the indolent tissue which existed 
there. 

Small fistulse can completely be extirpated and the healthy tis- 
sue can be brought together and made to heal by first intention. 
With careful antiseptic precautions this method may be carried out 
in cases of fistula in ano, which are usually tubercular in origin. 
In cases in which neither incision nor excision are applicable the 
thermo-cautery may be used with success. 

Medicated injections that may be used to exert a healing influ- 
ence upon the walls of a fistula are numerous. Solutions of car- 
bolic acid (1 : 200) or phenyl (1 : 250) may be employed for the pur- 
pose of disinfection. Corrosive sublimate is not so useful for this 
purpose, owing to its inability to penetrate greasy substances and 
its conversion into an inert aluminate. 

If there is reason to suspect tuberculosis, a weak solution of 
tincture of iodine, of about the color of sherry wine, is an efficient 
application. A 10 per cent, emulsion of iodoform in glycerin, and 
Krause's emulsion, which also contains gum arabic and carbolic 
acid, are valuable remedies in tuberculous fistulse. Peroxide of 
hydrogen may be employed as a cleansing agent for fistulous ulcers. 



192 SURGICAL, PATHOLOGY AND THERAPEUTICS. 

A very weak solution of nitric acid (i drop to the ounce) is often 
effective in healing small fistulse connecting with bone. The suc- 
cess of this treatment may be due to the antibacterial virtues of 
the acid or to its solvent action in the carious or necrotic bone. 
Attention should be given in all cases to the general condition 
of the patient and his surroundings. A chronic fistula has often 
been known to heal after some acute intercurrent disease, such as 
scarlet fever. A thorough change in the habits of life may also 
bring about the same result. Tonics and non-irritating diet would 
be valuable adjuncts to such treatment. 



VIII. INFECTIVE INFLAMMATION. 

Acute Osteomyelitis. 

Acute osteomyelitis is a disease which furnishes our hospitals 
with the greater portion of the cases of necrosis that students are 
accustomed to see operated upon in the amphitheatre, but, although 
so common, it has escaped general attention from surgeons in its 
earlier stages. It is only the sequelae of the disease that one 
usually has an opportunity to study. The disease-process itself 
runs an acute course, and at times presents a group of symptoms 
of so grave and so obscure a character that its true nature is fre- 
quently overlooked. It has often been mistaken for typhoid fever 
or for acute rheumatism; hence such names as "bone typhoid," 
etc. The pathological anatomy of the disease has only been inter- 
preted correctly within comparatively recent years. The older sur- 
geons who had occasion to open the abscesses that formed in the 
early stages of this affection found the collection of pus between 
the periosteum and bone, and concluded that they had to deal with 
a suppurative periostitis; the same mistake is frequently made at 
the present time. Now that more is known about the etiology of 
the disease, and the fact is recognized that these acute bone-suppu- 
rations are caused by the growth of the pyogenic cocci, whether 
they arise in the medulla, the spongy or the cortical bone, or the 
periosteum, and that frequently all these portions of the bone are 
involved, it seems important to discard a nomenclature which gives 
but an imperfect idea of the nature of the disease, and to employ 
the more comprehensive term osteomyelitis. 

This form of bone-inflammation is seen most frequently in child- 
hood. A young lad bruises or sprains his leg during play or 
exposes himself for an unusual length of time to wet and cold. 
Presently acute febrile symptoms usher in an attack of illness, and 
it is soon discovered that the knee-joint is apparently involved in a 
rheumatic inflammation. A more careful examination shows the 
seat of the morbid process to exist in the lower portion of the femur 
or in the upper end of the tibia. The local symptoms become more 
marked, and the constitutional disturbance may be so great that in 
exceptional cases the patient succumbs in a few days to symptoms 
is iy3 



194 SURGICAL PATHOLOGY AND THERAPEUTICS. 

of septicaemia. In the majority of cases the formation of an abscess 
is soon apparent, and with the outlet of the pus the general symp- 
toms subside. The wound thus made does not heal, and after 
months of waiting the patient applies to a surgeon, who finds a 
mass of dead bone at the bottom of the fistulous tract. Such a 
condition, if not relieved by surgical interference, may last a life- 
time, or the patient may die eventually from the effects of pro- 
longed suppuration. 

The etiology of this disease is now thoroughly understood, a 
large number of observers having identified the pyogenic cocci as 
the organisms which are found in the pus from these bone-abscesses. 

Pasteur was one of the first to recognize the fact that this inflam- 
mation of bone was caused by a micrococcus, and Ogston found 
pyogenic cocci in the pus of a case of osteomyelitis. At one time 
in the early history of these experiments in France and Germany 
it was supposed that a specific organism was the cause of the dis- 
ease, but later studies have shown this theory to be untenable. 
Rosenbach made one of the first systematic studies of the bacterial 
origin of the disease, and in fifteen cases of osteomyelitis he found 
the staphylococcus fourteen times — once with the albus and once 
with the streptococcus — and in the fifteenth case he found the 
albus alone. He succeeded in imitating successfully Kocher's 
experiment, which consisted in the injection of pus into the vein 
of an animal after fracture of one of its bones, thus producing sup- 
puration of the bone. Rosenbach' s inoculations were made with 
the pure culture of the aureus, and suppuration was invariably pro- 
duced if the bone had previously been fractured. 

Among the most elaborate experiments are those of Courmont 
and Jaboulay. These observers injected two drops of a culture of 
the staphylococcus into the veins of a young rabbit, which was 
taken ill in forty-eight hours with swelling of both knees. Death 
occurred at the. end of eight days. Abscesses were found in both 
kidneys and in the muscles, particularly those of the heart. Sero- 
purulent arthritis of the knee-joint was also found. Congestion in 
the epiphyseal region of the lower extremity of the corresponding 
thigh was observed. In similar cases evidences of periostitis were 
seen, and sequestra were found near the epiphyseal line. Pus from 
an abscess of the arm produced, on injection, medullary abscesses 
in rabbits a few weeks old. Streptococci taken from a case of puer- 
peral septicaemia produced abscesses in the ends of the long bones 
of rabbits near the epiphyseal cartilages. 

These observers conclude that this disease may be caused by both 



INFECT1 1 r E INFLAMMA TION. 195 

the staphylococcus and the streptococcus. The staphylococcus 
attacks the juxta-epiphyseal regions, producing a periostitis with 
necrosis and sometimes inflammation of the joint. It reproduces 
pretty accurately the juxta-epiphyseal osteo-periostitis of man, 
whereas the streptococcus seems to attack the medullary cavity — 
usually near the juxta-epiphyseal line — and produces a more diffuse 
suppuration. 

Ullmann states as the result of a large number of carefully-con- 
ducted experiments that he was unable to produce the disease by 
injections of the virus unless some kind of injury had previously 
been inflicted upon the bone. The application of a temporary 
ligature to a rabbit's leg for from twelve to fourteen hours was 
found to cause certain changes in the marrow of the bones, partic- 
ularly extravasations and circumscribed hemorrhages, which were 
sufficient to predispose these parts to infection. Ullmann considers 
the staphylococcus as the usual cause of osteomyelitis. 

Kraske obtained in two out of five cases of osteomyelitis a pure 
culture of the aureus. In three cases numerous organisms were 
seen, among them being two forms of bacilli. Those cases in 
which several kinds of bacteria were found appeared to be of a 
more malignant type, as when a mixed infection of streptococci 
and bacilli was found. 

Kraske points out that many cases closely resemble pyaemia in 
their origin. It often happens that an osteomyelitis may originate 
from an abscess of the skin or of the subcutaneous connective tis- 
sue which has already healed. This author suggests that the tonsil 
may also be the point of entrance of the virus. He doubts the 
possibility of an invasion through the intestinal tract, but thinks 
that the respiratory organs may offer an entrance to the bacteria. 
It is quite probable that the virus often enters through excoriations 
or bruises or small wounds in the skin. The recurrent forms seen 
in adult life are explained by Kraske as due to the presence of 
spores which have remained for a long time encapsuled, and have 
eventually been freed from their long imprisonment. It is pos- 
sible, however, that a second attack may be due to a new infection. 
The first attack appears to create a predisposition to a second one. 
The exanthemata produce a condition also favorable to the occur- 
rence of osteomyelitis by manuring the soil, as it were, for the 
growth of the pyogenic cocci. Park showed that abscesses of bone 
and the periosteum may be caused, in a certain number of cases, 
by a mixed infection of the pyogenic cocci with the typhoid bacilli 
or with the bacilli of tuberculosis, and possibly also with the virus 



196 SURGICAL PATHOLOGY AND THERAPEUTICS. 

of syphilis. Changes in the bone-marrow are set up in a large 
number of infectious diseases, such as typhus, typhoid, or intermit- 
tent fever, and suppurative changes can easily be established in the 
bone under these circumstances. 

According to some observers, the typhoid bacillus is capable of 
producing suppuration. Frankel found only the typhoid bacilli in 
an abscess of the abdominal wall after typhoid fever, but Park 
found the staphylococcus with the typhoid bacilli under similar 
circumstances. These bacilli have been detected in subperiosteal 
abscesses by Ebermaier, who considers that they reach the perios- 
teum from the medullary part of the bone through the Haversian 
canals. Park observed only the pyogenic cocci in post-scarlatinal 
abscesses: whether a specific organism of the disease is also present 
can only be determined after the nature of scarlatinal virus is 
understood. It is possible that the specific organisms of certain 
diseases may become localized elsewhere at first, and, when the 
system is debilitated by the effects of the disease thus produced, 
bring about suppuration in the bones. 

Koplik found pure cultures of the streptococcus in several cases 
of osteomyelitis in infants, but, as this author states, all the cases 
belonged to the so-called " septico-pyaemic " class. Cultures of 
these organisms injected into the circulation of healthy rabbits 
caused an inflammation of the joints of the posterior extremities, 
terminating in suppuration. The medulla of the bones correspond- 
ing to these joints was invaded with streptococci. These experi- 
ments suggest the theory that cases of multiple osteomyelitis are 
due to the agency of the streptococcus. 

A glance at the a?tato?ny of the ends of the long bones throws 
some light upon the selection of this particular point as the seat 
of suppurative disease. This region is called by Oilier ' ' the zone 
of election of pathological processes. ' ' Near the Epiphyseal carti- 
lage, which separates the diaphysis or shaft from the epiphysis, 
there exists in growing bones a newly-formed spongy tissue, very 
vascular and connected with the cartilage by a spongy layer of tis- 
sue, which is not yet bone, but which does not possess a cartilag- 
inous structure. It is in this portion of the organ that the most 
active changes take place during the period of growth. The 
medullary substance is very vascular at this point: it is red and 
without fatty tissue. It communicates with the medullary canal 
and with the periosteum by a number of vascular channels. The 
epiphyseal cartilage itself is intimately blended with the perios- 
teum. The diaphyseal side of the cartilage produces much more 



INFECTIVE INFLAMMATION. 



197 



bone than is found on its epiphyseal margin. There is also an 
active growth of bone in the periosteum, and it is in these regions 
and in the medullary canal that the inflammatory processes orig- 
inate. The question has been asked whether the disease begins at 
that end of the bone toward which the nutrient artery is directed. 
If this were the case, the fact would suggest for the inflammation 
an embolic origin which probably does not occur. In the femur 
the artery is directed upward, yet the lower portion of the bone 
is most frequently affected. The reverse conditions exist in the 
tibia. 

The compact bone is never primarily affected ; in fact, the bony 
tissue is of minor importance in this form of inflammation. As 
might be expected, the disease is most frequently seen during the 
period of active growth in the bone. It is much less frequently 
seen in women than in men, but this is probably due to the fact 
that the former are less exposed to injury. 

Among other predisposing causes are those which bring about 
an enfeebled condition of the system, such as unhealthy surround- 
ings and poor food or long exposure and fatigue. In enfeebled 
individuals the tissues are less resistant to the action of bacteria. 
Ullmann was able to produce the disease experimentally, by injec- 
tion, in animals suffering from a considerable loss of blood, and he 
found that in these cases no previous 
injury of the bone was necessary. 

Some slight injury, such as a blow, 
not unfrequently a kick, given to a boy 
by his playmate, or a sprain, is sufficient 
to produce in this delicate tissue, with 
its rich vascular supply, a bruising of 
the vessels and an effusion of blood — at 
all events, a certain amount of damage 
which temporarily interferes with the 
nutrition of the part. Minute fractures 
of the bony trabeculse not unfrequently 
are found after such injuries. At these 
points the bacteria which may be circu- 
lating in the blood move in a compara- 
tively confined vascular area, and readily 
find lodgment in the bruised tissues or 
the blood-clots. Where the pathological 
process originates the unyielding nature of the tissues favors, at 
times, a rapid spread of the inflammation through the Haversian 






>:> Q- 



A 




Fig. 37. — Point of Origin of Sup- 
puration in Osteomyelitis. 



198 SURGICAL PATHOLOGY AND THERAPEUTICS. 

canals, through which the blood-vessels pass. At other times the 
inflammation remains for a period localized (Fig. 37). 

The red color of the medulla of youth is preserved in the bones of 
the trunk and the head during growth and in adult life, but it is lost 
in the medulla of the bones of the extremities, where the tissue is of 
a yellow hue, due to the presence of fatty tissue. In osteomyelitis 
this tissue becomes reddened, but unlike the normal medullary tint, 
and there is an increase in the consistency of the tissue. The fat- 
cells disappear, and the part becomes infiltrated with granulation- 
cells and some red corpuscles. There is, in fact, a great increase in 
the number of leucocytes and of cells containing red masses and pig- 
ment-granules, and an increase also in the number of leucocytes 
throughout the organism, so that an u inflammatory leukaemia" 
has been said to exist. The spleen may be enlarged, and hemor- 
rhagic exudations are often found in the serous cavities. Ullmann 
found, in dogs with osteomyelitis, that the leucocytes were increased 
from four- to sixfold. The inflammatory exudation is not diffuse, 
however, but collects at numerous foci, which give to the part a 
mottled appearance due to local congestions and to extravasations 
of blood. As these foci soften they turn yellowish-gray or dark 
red according to the amount of blood or pus they contain. The 
bone, on section, shows collections of pus or of spongy tissue infil- 
trated with pus. The numerous abscesses are varied in form and 
size, and are often arranged in rows near the epiphyseal cartilage. 
As soon as suppuration is established there forms a line of granula- 
tions which separates the diseased from the healthy tissue. New 
tissue is formed both in the medulla and in the periosteum, con- 
taining many osteoblasts, which are capable of producing new 
bone. An absorption of tissue takes place at these points, thus 
separating the dead from the living bone. 

As the amount of pus increases, it either spreads by infiltration 
along the interior of the shaft of the bone or it works its way 
through some of the natural channels (as the Haversian canals) to 
the surface, and accumulates beneath the periosteum, separating it 
from the bone (Fig. 38). When the pus breaks through this obstruc- 
tion it burrows next between the muscles, and it may form one or 
more distinct abscesses. The pus which they contain is at first of 
a brownish color, occasionally has a very foul odor, and is accompa- 
nied by the discharge of extensive sloughs. It frequently contains 
innumerable drops of medullary fat, which is said to be quite a cha- 
racteristic feature of these abscesses, and therefore to possess a cer- 
tain diagnostic value. This fat is due to increased pressure in the 



INFECTIVE INFLAMMATION. 



199 




Fig. 38. 



Extension of Suppuration in 
Osteomyelitis. 



medullary cavity, which forces the fat-drops through the Haversian 
canals. 

In many cases the epiphyseal cartilage remains intact through 
all this inflammation, and offers an ef- 
fective barrier against the spread of 
the disease toward the joint. In some 
cases, however, it is broken through 
and disappears, and the disease attacks 
the epiphysis. One joint may be af- 
fected either by a direct extension of 
the pus in this way through the bone 
or by the more circuitous route from 
abscesses which have perforated the 
periosteum and eventually have pushed 
their way through the capsule. As the 
epiphyseal cartilage is absent in the 
adult, the joint is more likely to be 
affected at this period of life. 

The effect of this acute suppurative 
process is to cause necrosis or death of 
the bone. When the shaft of the bone is involved in the ordinary 
way, a few fine, needle-like particles 
of dead bone may be found in the 
medullary canal during the first few 
days of the process. Later, larger 
fragments may be found to have sep- 
arated, either as exfoliations from the 
surface or as fragments from the denser 
portions of the medullary bone. When 
the pus reaches the periosteum, it may 
burrow for a long distance beneath it, 
and a large portion of the shaft may 
thus be deprived of its external blood- 
supply. As a consequence of this com- 
plication considerable portions of the 
bone may die, and in rare instances 
the whole diaphysis or shaft may be 
destroyed (Fig. 39). There then re- 
sults what is called "total necrosis" 
of the bone. Usually, however, only 

a small part of the shaft suffers, and the sequestra thus formed 
rarely exceeds one-third or one-quarter the length of this portion of 




Fig. 39. — Necrosis of the Shaft and 
Periosteal Formation of Bone. 



200 SURGICAL PATHOLOGY AND THERAPEUTICS. 

the bone. The extent of the necrosis is greater near the point of 
origin of the suppuration; that is, near the epiphyseal line, and at 
this point it may occupy the whole thickness of the bone. Nearer 
the middle of the shaft the necrosis is usually more superficial. It 
does not always follow that after the periosteum has been sepa- 
rated the portion of the bone thus exposed must necessarily die. 
Some of the periosteum thus separated may subsequently become 
reunited to the bone. The dead bone can usually be recognized, 
when inspected through freshly-opened abscesses, by its yellowish 
color and by the absence of the mottled appearance of normal 
bone. As the result of an extensive necrosis there may be, in 
rare cases, a spontaneous fracture of the bone at some point in its 
shaft. But this occurrence is usually prevented by the formation 
of new bone, which begins a few weeks after the old bone has 
been destroyed. Separation of the epiphysis also often occurs, 
but in the majority of cases the suppuration has only been sufficient 
to separate part of the epiphysis from the shaft of the bone. 

When the bone dies it becomes a foreign body, still attached to 
the adjacent live bone, but separated from its covering of perios- 
teum by a layer of pus. It lies, in fact, in the centre of an abscess. 
After the abscess breaks the periosteum comes more or less closely 
in contact with the shaft of the bone, and in a few weeks it is found 
that bony tissue is forming in the granulation layer lining the peri- 
osteal wall of the cavity. The formation of new bone takes place 
slowly, however, and it may be several months before sufficient 
bony tissue is found to supplant that which is gradually separating 
as a sequestrum. It is an important provision of Nature which 
does not permit the live bone to free itself entirely of the seques- 
trum until the work of the periosteum has been accomplished. 
Consequently, it is found that when the dead bone is fully separated 
and is ready to come away from the cavity in which it lies, it has 
become imprisoned in a wall of new bone (Fig. 40). The pus in 
which the sequestrum is bathed escapes through one or more fistu- 
lous openings in the newly-formed bone. In cases in which the 
periosteum has partly been destroyed by the septic process there 
will be no bony formation at that point, and the dead bone will 
then remain covered only by the soft parts, and can easily be 
reached and removed by the bone-forceps, or it may be forced out 
gradually from its bed by the exuberant granulations, or, if small 
in size, it may be expelled through a fistulous opening in the 
integument ; in rare instances large fragments of bone may be 
extruded in this way. The pus exerts only a slightly solvent action 



INFECTIVE INFLAMM. I TI( W. 



20I 



upon the necrosed bone, but there are nevertheless frequently sepa- 
rated from the larger sequestra bony spiculae, which from time to 
time are found in the discharges upon the dressings. The seques- 
trum is more likely to be affected by the young growing granula- 





FlG. 40. — Separation of Sequestrum and 
Formation of Involucrum. 



Fig. 41. — Unhealed Abscess-cavity, with 
Eburnation of the Surrounding Bony 
Tissue. 



tion tissue, by which small sequestra may entirely be absorbed. 
The large portions of dead bone may, however, remain for years 
imprisoned in their bony cavities. After all sequestra have been 
discharged a suppurating cavity frequently remains with no tend- 
ency to heal, owing to the rigidity of its walls (Fig. 41). Such 
cavities may eventually become tuberculous. The epiphyseal car- 
tilage in a certain number of cases remains intact; in other cases 
it is partially affected, and in still other cases it has disappeared, 
and under these circumstances it is usually found that the epiphysis 
or even the joint has been involved. Occasionally, as a result of 
the disorganization of the cartilage, there is a complete separation 
of the epiphysis from the diaphysis. 

The regeneration of the medulla takes place from the perivas- 
cular connective tissue in the Haversian canals which open into 
the medullary cavity, and also from those portions of the marrow 
that still remain at the epiphyseal ends of the bone. From these 
points is developed a gray connective tissue which eventually 
assumes all the characteristics of the old medulla. On the bor- 



202 SURGICAL PATHOLOGY AND THERAPEUTICS. 

ders of the newly-forming bone are found the osteoblasts from 
which the new bony tissue is developed. This new tissue is more 
porous and irregular in its arrangement than the old bone, and the 
bone-corpuscles it contains appear to be larger than those seen in 
normal bone-tissue. 

In some places an absorption of bone may occur as a result of 
the inflammation. Here are found in the porosities of the bony 
tissue the large giant-cells or osteoclasts through which absorption 
takes place. 

Occasionally there is found a bipolar ostitis, both juxta-epiphy- 
seal regions of the bone being affected simultaneously. The 
disease begins in these cases at one end of the bone, and the 
infective material is conveyed through the medullary canal to the 
other end. At times the route taken can be followed throughout 
the canal; at other times the infection leaves no sign of its pas- 
sage. In some cases these bone-inflammations may be multiple, 
several bones being thus simultaneously affected, such cases closely 
resembling pyaemia. The latter disease is not infrequently a sequel 
of the severer types of this form of bone-inflammation. Makin 
and Abbot report forty-one cases of bone-inflammation terminating 
fatally with symptoms of pyaemia. But many of the so-called 
cases of pyaemia originating from osteomyelitis are to be regarded 
as multiple osteomyelitis, the pyogenic cocci in such instances con- 
fining themselves to the osseous system. Such forms of osteomye- 
litis run a far more favorable course than pyaemia. In combination 
with such types there may be ulcerative endocarditis. Such a case 
has recently occurred in the hospital ward. A boy, twelve years of 
age, suffering from osteomyelitis of the shaft of the left tibia and 
the clavicle, had also marked valvular disease. The clavicle was 
treated by the removal of a large sequestrum involving the entire 
shaft of the bone, and amputation through the lower third of 
thigh was performed, as ^repeated operations by different surgeons 
failed to arrest the suppurative process in the tibia. 

True pyemia, however, may follow the outbreak of a violent 
type of osteomyelitis, and in certain cases the patient may die in a 
few days after the development of inflammation from septicemia. 
The latter complication sometimes follows the opening of a bone- 
abscess. Such a case recently came under the writer's observa- 
tion. The patient, a gentleman of about sixty years of age, had 
many years before suffered from osteomyelitis of the right femur, 
which had healed without necrosis of any extent. The abscess had 
been forming for about fourteen days, and when opened a large 



INFECTIVE INFLAMMATION. 203 

amount of fetid pus and sloughs was discharged, and the patient 
rapidly succumbed to acute septicaemia, which supervened. This 
case illustrates also the tendency to recurrence, which, after years 
of apparent health, the disease sometimes shows. These recurrent 
forms are said to be due to spores which have become encapsuled, 
and, owing to some local disturbance, have become free again. 

Osteomyelitis is not always found in the long bones. It may 
have its seat in both the short and the flat bones. It is, however, 
much more rare in the latter situation, and many of these cases are 
mistaken for tuberculosis. In fifty-one cases reported by Frohner 
the clavicle was found diseased eleven times, the scapula nine 
times, the ileum nine times, and the os calcis seven times. The 
disease may occasionally be situated in the so-called "joint 
region," and it then constitutes what is called epiphyseal osteo- 
myelitis. There is in this form of the disease a primary localiza- 
tion of the inflammation in the articular extremity of the bone; 
that is, between the epiphyseal and articular cartilages. Under 
these circumstances the joint is involved at an early stage, for the 
more vascular epiphyseal cartilage offers a barrier to the spread of 
the disease toward the shaft of the bone, and the pus can therefore 
spread only in the direction of the articular cartilage. The joint 
affection soon overshadows the disease of the bone, and the patient 
presents the symptoms of a joint inflammation, the origin of which 
can only be brought out by a careful study of the case. Jordan, 
who reports two such examples, advises an early opening of the 
joint before it has been destroyed. Many such cases have undoubt- 
edly been mistaken for tubercular disease. 

We next come to a consideration of the symptoms of osteomye- 
litis. As the reader has already seen, this disease occurs most fre- 
quently in youth and after some slight injury or from exposure, 
or perhaps from no known cause. The patient suffers for several 
days from prostration, and complains of pain in some one joint or 
in the adjacent bone. Presently a severe chill occurs, which is 
followed by high fever, frequently of a typhoidal character. The 
pulse is weak and rapid and the face is flushed, the expression in 
the gravest cases being one of fright and stupefaction. The tongue 
is dry and coated, and there is frequently some delirium. The 
spleen is slightly enlarged, and there is often a foul diarrhoea. 
These are the symptoms of a grave septic infection of the system, 
probably from the ptomaines or toxines set free by the invasion of 
the bacteria. At first the only local symptom may be pain, but 
presently a swelling can be observed in the neighborhood of some 



204 SURGICAL PATHOLOGY AND THERAPEUTICS. 

joint, such as the knee, the shoulder, or the elbow, followed soon 
by more or less oedema of the adjacent soft parts, which oedema 
usually surrounds the affected limb. The swelling spreads in the 
direction of the axis of the bone, and the skin becomes cedema- 
tous and the veins enlarged. Although the skin may not yet have 
changed color, the part is excessively painful to pressure, the slight- 
est movement of the limb causing the patient to cry out lustily. 
The pain is of a boring or almost breaking character, and at times 
throbbing; it is not necessarily always near the epiphyseal line, 
but may be near the middle of the shaft: it may exist for several 
days before the most careful examination can detect any local 
change or swelling. As the color of the skin changes to a reddish 
hue signs of fluctuation appear, and if the abscess is now opened 
the pus discharged is of varying character, according to the partic- 
ular conditions of the case. At times the pus may be foul and filled 
with fragments of slough and decaying blood. Again, the pus may 
be found comparatively typical in character, and it will then be 
perceived that there are innumerable minute drops of fat floating 
in it. These fat-drops arise, as has been explained, from the 
decomposed medullary tissue, having forced their way out through 
the Haversian canals. Often, at this time, it will be found that 
the joint has begun to sympathize, and there may simply be catar- 
rhal synovitis due to the neighborhood of the severe inflammation, 
or the joint, from having become infected, has begun to suppurate. 
In rare cases the disease in a bone can thus infect both articular 
cavities with which it is in contact. 

The lungs are often also the seat of inflammations at this period, 
which inflammations may be caused by fat-embolism, such as is 
often observed after extensive fractures. This complication is seen 
in the early stages of the disease, and appears as a diffuse catarrh 
with abundant expectoration or with symptoms of oedema of the 
lung. Later pneumonia may be found developing, caused by ^v £ 
emboli which have been detached from infected thrombi formed a 
in the rich venous network in the medullary tissue. Metastatic 
deposits may also be found occasionally in other organs, such as 
the kidneys, and the symptoms of a genuine embolic pyaemia may, 
in rare instances, gradually develop. In the majority of cases, how- 
ever, the situation is not so grave, and with the discharge of pus 
from the abscess the fever subsides and the case assumes a chronic 
type. It may then be found that the heart has been involved, and 
that there has been developed an endocarditis due to the attachment 
of the bacteria to the endocardium. 



INFECTIVE INFLAMMATION. 205 

Returning, now, to the abscess which has just been opened, it 
will be found, on introducing the finger into the wound, that the 
bone has been denuded of its periosteum. If the pus has burrowed 
beneath the periosteum, the bone will be exposed for a considerable 
distance, and the surgeon will be somewhat startled to feel his 
finger gliding over the smooth and slippery surface of the shaft 
of the bone, which may be completely separated from the soft 
parts surrounding it. At other times an incision down to the bone 
may not liberate pus, and it then becomes necessary to open the 
interior of the bone before the seat of the suppuration can be dis- 
covered. With the discharge of pus the severity of the constitu- 
tional disturbance abates. As the suppuration gradually diminishes 
in quantity the fever disappears, leaving the patient greatly emaciated 
and with one or more sinuses leading to the diseased or dead bone. 

As has already been seen, more than one bone may be affected 
at the same time, and this appears to be due not necessarily to 
metastasis, but to the simultaneous affection of one or more local- 
ities ; at all events, these cases of multiple osteomyelitis must not 
be classified with those which succumb to genuine embolic 
pyaemia. The clinical picture in the two types is a very different 
one. The various points of inflammation develop synchronously 
or nearly so, and the virus does not appear to follow the laws of 
dissemination that hold in pyaemia. Many of these foci of inflam- 
mation may not come to suppuration. A tender lump may form 
at the end of a bone, and may subsequently disappear by resolu- 
tion. At some of these points there appears to be a new formation 
of bony tissue instead of suppuration, and cases have been reported 
in which an increased length of the bone has resulted from inflam- 
matory hyperaemia. 

In not a few cases — particularly in infants and in young chil- 
dren — acute suppurative arthritis may occur as a result of the 
extension of the disease through the tender tissue of the epiphys- 
eal cartilage. This form of osteomyelitis is frequently secondary 
to some of the exanthemata or to diphtheria or to pneumonia, and 
may be observed in many of the children frequenting the out-pa- 
tient department of a large hospital. The amount of bone-destruc- 
tion may in such cases be small, and the bone and joint may be 
restored to the normal state. This is the class of cases referred 
to by Koplik and Van Arsdale as being caused by the streptococ- 
cus infection. These authors recognize two forms of streptococcus 
osteomyelitis. In the mild form the disease is non-articular, the 
constitutional disturbance is slight, and it corresponds to Volk- 



206 SURGICAL PATHOLOGY AND THERAPEUTICS. 

mann's catarrhal inflammation of the joint. The local inflamma- 
tion is an acute one, and the joint suppurates, but the disease yields 
readily to surgical interference, and the function of the joint is 
gradually re-established. The grave type of the disease is insidious 
in its onset, the first thing noticed by the mother being the consti- 
tutional disturbance. "The child, if brought to the physician's 
attention, at once awakens solicitude. It lies quietly, pale, with 
sunken eyes surrounded by dark rims ; its tongue is coated, fulig- 
inous ; its skin is dry, its temperature not being very high, how- 
ever." Occasionally there are symptoms of pain, indicated by 
sharp little cries, and when certain parts are touched the suffering 
of the child is very great. In later stages the swelling of the 
joints is more pronounced. Several joints are usually affected, 
and aspiration reveals pus. Many of these cases belong to the 
class which has incorrectly been classified with pyaemia. Closer 
examination shows that the suppuration has emanated from the 
shafts of the bones, and that this portion of the bone may at times 
become extensively involved in the disease. 

The diagnosis of acute osteomyelitis may, under certain circum- 
stances, be attended with unusual difficulties. Most frequently the 
disease is mistaken for acute articular rheumatism. If a child is 
attacked in one or more joints simultaneously with symptoms of 
acute inflammation, and, later, symptoms of cardiac complication 
are developed, it is not surprising that the treatment selected 
should frequently be the administration of salicylic acid. Occa- 
sionally a patient is brought into the hospital in a more or less 
comatose condition, and it is only with great difficulty that there 
can be obtained from his friends anything approaching a history 
of the case. If under these circumstances there is as yet little 
local swelling around the focus of inflammation, it is not improb- 
able that the diagnosis of typhoid fever might be made. 

The disease does not always confine itself to the long bones, for 
not infrequently it is found that the carpus and tarsus, and some- 
times the flat bones, like those of the cranium, are affected. Such 
cases might be mistaken for tuberculosis. 

Tuberculous inflammations, however, are of a chronic type, 
while pyogenic inflammations are always acute. In doubtful cases 
the local conditions must carefully be studied, particularly with 
reference to their history. It will then be found that the pain is 
first noticed near the joint, and that pressure will bring out the 
fact that an acutely sensitive spot exists near the epiphyseal line. 
It is undoubtedly the fact at the present time that the true nature 



IN FECI 1 1 F IX FLAM MA WON 



207 



of these cases is not generally understood. Attention has not yet 
been drawn toward this subject, particularly to the importance of 
an early diagnosis, which may result in saving from destruction 
not only the bony tissue, but also a joint. The danger both to 
life and to the welfare of a limb is so great that it is to be hoped 
that those who see these cases in the early stage will realize the 
importance of a correct diagnosis and the necessity for prompt treat- 
ment. Much harm has been done by a former generation of surgeons, 
who taught that these cases were the result of periostitis — a diagnosis 
which inevitably leads to incorrect views as to the proper treatment. 

The most frequent sequel of this disease is necrosis, which may 
be recognized by the presence of a fistulous opening leading to the 
dead bone. A probe introduced will readily detect the hard, 
smooth, bony substance lying at the bot- 
tom of the sinus. Occasionally the sinus 
is simply filled with flabby granulations, 
and it is probable that portions of the dead 
bone have been expelled by the pressure of 
the granulation tissue that has developed, 
or that the sequestra, if small, have been 
absorbed. The amount of bone disposed 
of by the process of absorption is in most 
cases exceedingly small, and large sequestra 
often remain for years unaltered (Fig. 42). 

Spontaneous fracture is exceedingly rare. 
The writer remembers having seen but two 
examples. Separation of the epiphysis oc- 
curs, according to Ullmann, not as the result 
of the disintegration of the epiphyseal carti- 
lage, but in consequence of a suppuration 
through the lower portion of the shaft, and 
it appears to occur quite independently of 
necrosis. 

In some cases the inflammatory symp- 
toms subside without the discharge of pus, 
and the patient appears to have recovered 
from the attack. Pain, m however, recurs 
from time to time, and the patient may 
suffer for years from attacks of neuralgic 
pain, arising chiefly at night. There may 
be little if any enlargement of the bone to indicate the seat of the 
inflammatory process. Finally, an operation discloses an abscess 




Fig. 42. — Necrosis of Femur, 
the result of Acute Osteo- 
myelitis. 



208 SURGICAL PATHOLOGY AND THERAPEUTICS. 

situated usually near the epiphyseal end of the bone. The cavity 
formed in the bone has usually a smooth surface and contains true 
pus. The surrounding bony tissue is much denser than in the 
normal condition, and frequently presents the condition known as 
ebumation (PI. I.). These abscesses are usually small, and they 
contain a drachm or two of pus, but occasionally they may attain 
great size. Stanley describes such a bone-abscess, the opening 
into which was closed by a cork that the patient was in the habit 
of wearing to protect himself from the discharge of pus. 

Dislocation may occur as the result of several conditions. The 
joint may have become disorganized by the extension of the inflam- 
mation, the capsule and ligaments being then relaxed or partially 
destroyed. Roser has explained some forms of dislocation by an 
unusual growth of the ligaments due to hyperemia near the 
necrosed bone. In some cases the growth of the bone is arrested 
by the destruction of the epiphyseal cartilage. If there is an 
adjoining bone which continues to grow, a displacement of the 
head of the adjacent bone may result. Nelaton mentions such a 
displacement of the head of the fibula in consequence of an arrest 
of development of the tibia. 

In rare instances the granulations which protrude from the fis- 
tulous openings may begin to assume an active growth and the skin 
around becomes more or less infiltrated. The discharge is then 
more purulent in character, and it has an offensive odor. A new 
growth, which proves to be carcinoma, is taking place in the gran- 
ulation tissue. Volkmann has collected thirty-two examples of 
this complication. Prompt amputation of the affected limb is of 
course the only remedy, as an early involvement of the inguinal 
glands may take place. 

The prognosis of the disease varies, as may easily be judged, 
from the severity and the extent of the inflammation. The grave 
types of osteomyelitis that terminate fatally in a few days are hap- 
pily rare. This form is perhaps most frequently seen in young 
children or in infants, and it is usually due to a streptococcus 
inflammation. 

In a large majority of the cases the severe constitutional disturb- 
ance may subside in due time, and the chronic stage of the disease 
may be prolonged indefinitely. Nature does not appear equal to 
the task of removing the dead bone from its newly-formed cavity. 
The spontaneous removal of all sequestra is the exception. Even 
an empty cavity may be unable to heal, owing to the inability of 
its bony walls to shrink, and a ' ' bone-fistula ' ' may remain as a 



PLATE I 





Shaft of the Femur, showing the results of osteomyelitis. Thickening of bone with 
eburnation. The sequestra have long since been discharged. 



INFECTIVE INFLAMMATION. 209 

permanent condition (PL L). In some cases when the necrosis 
has been extensive, and when the suppuration has been pro- 
longed and excessive, the patient may become greatly emaciated, 
and eventually amyloid degeneration of the internal organs may 
supervene, which condition is soon followed by a fatal termination 
of the case. 

Since the pathology of osteomyelitis has been recognized and 
the point of origin of the inflammatory process has been definitely 
determined, the question of treatment has been much simplified. 
This is a disease which is caused by pyogenic cocci, and which ter- 
minates with hardly a single exception in suppuration. It is true 
that a certain number of cases are reported where the symptoms- 
have subsided and the inflammation has terminated in resolution 
instead of in suppuration. Such cases are probably not true cases 
of acute osteomyelitis. 

Counter-irritation, which was a mode of treatment much in 
vogue in former times, may be discarded. It is known that the 
actual cautery may in experimental cases of inoculation with pus- 
cocci prevent suppuration by stimulating the absorption of these 
organisms before they have had time to multiply, but such an agent 
would hardly act upon the deeply-seated foci, the presence of which 
in bone is not detected until the disease has made too much prog- 
ress to be checked. In the early stages, before a diagnosis has 
been made, much may be done to mitigate the sufferings of the 
patient. The limb may be immobilized by a splint and pain be 
relieved by the application of ice-bags or of poultices. The treat- 
ment of this disease from the earliest moment that a diagnosis can 
be made is eminently a surgical one. As in cases of suppuration 
in the abdominal cavity, pus must be removed before it has an 
opportunity to effect serious or fatal injury. Although in appendi- 
citis some surgeons still hesitate to operate, as many cases recover 
without suppuration, in osteomyelitis pus is always formed, and 
must be removed — the sooner the better. 

The problem differs somewhat according to the stage the disease 
has reached when the patient first comes under observation. In 
the earliest period the pus is still confined to the interior of the 
bone, and a well-formed abscess may not yet have developed. It 
is uncertain whether the virus may not infiltrate the whole medulla 
and destroy the entire shaft or endanger the life of the patient. In 
these cases an opening should not only be made to allow the pus to 
escape externally, but an attempt should also be made to remove 
the infected area itself, and thus to arrest the inflammation. Some 

14 



2io SURGICAL PATHOLOGY AND THERAPEUTICS. 

writers advise an attempt to remove the pus by boring with a drill 
numerous small holes through the soft parts and the bone. This 
is Ullmann's method, who makes the punctures from 2 to 3 
centimetres apart. Kocher not only punctures the bone, but also 
injects carbolic acid with a view to disinfecting the foci of suppura- 
tion. Such procedures seem hardly suited to ordinary cases of 
bone-suppuration, but might be used on some of the smaller bones, 
such as the alveolar processes of the jaw, where the amount of pus 
is exceedingly small. In typical cases of this disease a prompt 
incision should be made through the soft parts to the bone, which 
must then be opened with the gouge or with the trephine. Fre- 
quently no signs of inflammation will be detected until the medulla 
has been reached; then a few drops of pus, collected in small foci, 
may be revealed, or the discharge may merely be of a sero-puru- 
lent character, or the medullary tissue may be gangrenous. The 
infected portions of the medulla must carefully be scraped away, 
and if this operation is thoroughly performed the wound may be 
left in a completely aseptic condition. The wound should not be 
closed, but, after having been thoroughly washed out with some 
disinfectant, should be stuffed with iodoform gauze. The result of 
this treatment is subsidence of the febrile symptoms and great 
relief of the pain. If, however, the high temperature recurs and 
the bone again becomes painful, it may be necessary to enlarge the 
bony opening and to scrape away any portion of the medulla found 
to have become infected. A stout, sharp curette is the most useful 
instrument for this purpose: it should be made in various sizes, so 
as to reach all corners of an infected area. The Esmarch bandage 
should always be applied before operating upon the bones of the 
extremity, the surgeon being thus enabled to carry out with great 
precision all the details of the operation and to see with great ease 
all the pathological changes. 

When the pus has reached the surface the periosteum is dis- 
sected from the bone for a certain distance and the soft parts are 
invaded. This condition is readily recognized by the swelling and 
the redness of the surrounding integuments. In such cases the 
external abscess must be laid open and disinfected by curetting 
and by washing its walls; the periosteum must be opened freely, 
and a search must also be made for the point of origin of the 
inflammation in the bone. This is a precaution which surgeons 
often neglect, thinking that the case is one of "suppurative 
periostitis," and that it is unnecessary to search farther. The 
teachings of pathology must be remembered here, and search for 



INFECTIVE INFLAMMATION. 2ir 

pus must be made near the epiphyseal Hue. No operation which 
does not include an opening into the bone should be regarded as a 
completed one. French surgeons have long recognized the import- 
ance of this detail. Lannelongue advises that the trephine should 
be placed near the epiphysis, and that a second opening should be 
made into the shaft of the bone to open the medullary canal, which 
in young subjects does not always reach to the epiphyseal line. If 
the periosteum has peeled off for a great distance, it may be neces- 
sary to make a third opening. Trephining, he thinks, should also 
be employed in osteomyelitis of the flat bones, such as the cranium. 
Multiple openings are only advisable in very extensive disease of 
the medulla. Under ordinary circumstances an opening near the 
epiphyseal line should be made, and be sufficiently enlarged with 
the chisel or the gouge to expose the diseased area. 

Formerly it was advised not to open these abscesses until the 
last moment, when the surrounding inflammation had had time to 
protect the tissues from the decomposing medulla. It was found 
that in many cases of early opening the patient succumbed to 
septic infection, but this rule does not hold good at the present 
time. The custom serves, however, to emphasize the importance 
of thoroughly opening and disinfecting these treacherous abscesses. 

So serious were the results following these operations before the 
days of antiseptic surgery that amputation was freely advised as the 
only means of saving life. The fine specimens of bones containing 
sequestra in many of our museums are silent testimony to the pop- 
ularity of the discarded treatment. Chassaignac laid down careful 
rules for amputation in this class of cases, and Roux held that 
disarticulation was the only proper remedy, as amputation through 
the continuity of a bone did not avail to prevent the spread of the 
inflammation. Amputation is now resorted to only in exceptional 
cases, when all other means fail to arrest the suppuration or the 
case approaches a fatal issue. When such abscesses have been 
opened and disinfected drainage-tubes should be introduced down 
to the medulla, and the abscess-walls should be packed with iodo- 
form gauze. The whole limb is then swathed in a voluminous 
antiseptic dressing and is placed upon a splint. If all goes well, 
this dressing need not be changed for several days. But if consti- 
tutional disturbance continues, the dressing should be removed and 
the wound be thoroughly washed out with a disinfectant. A moist 
antiseptic dressing may in such cases be substituted for the dry 
dressing. A large cotton poultice soaked in a solution of sulpho- 
naphthol (i : 250) may be applied and changed once or twice a day. 



212 SURGICAL PATHOLOGY AND THERAPEUTICS. 

In those cases where the joints are involved — which complica- 
tions occur chiefly in infants and in young children — the following 
rules, laid down by Van Arsdale, should be observed: As soon as 
the joint appears swollen and becomes painful, it should be aspi- 
rated under the strictest antiseptic precautions, and if pus is found 
the joint should be laid open, drained, and dressed antiseptically. 
Usually one incision will be sufficient for this purpose, but in some 
instances counter-openings with packing of the joint, or even resec- 
tion of the joint, may be necessary. Resection of the hip is more 
frequently performed than that of the other joints. Volkmann 
found the prognosis more favorable in resection of the hip for 
this disease than for tuberculosis. Special attention should also 
be given to the shaft of the bone in these cases, and incisions 
should be made for the purpose of exploring this portion of the 
bone. If it is necessary to remove portions of the shaft, Van 
Arsdale dwells upon the importance of working upon the two 
regions separately, with the view of sparing, as much as possible, 
the epiphyseal line, and thus giving an opportunity for the future 
development of the bone. 

Many cases of osteomyelitis resist all efforts to arrest the inflam- 
mation. Suppuration continues, and the shaft of the bone may 
become more or less disorganized. In other cases the pus may 
burrow so freely under the periosteum as to denude the entire 
shaft. Under these circumstances the question has been raised as 
to the justifiability of a resection of a considerable portion of the 
shaft of the bone. Oilier recommends this operation only as a last 
resort. It should be performed as late as possible, as the perios- 
teum may then have reached the reproductive stage. The objec- 
tion to this operation is the uncertainty of the reproduction of the 
bone; a large number of operations are reported where only a par- 
tial renewal of the diaphysis has taken place. Marchant reports 
a case of resection of the shaft of the tibia in a child sixteen years 
of age. This patient, when seen five years later, walked on the 
side of the foot. A case of resection of two-thirds of the inferior 
portion of the radius was followed by forced extension of the hand 
backward and outward. Marchant reports successful cases of resec- 
tion of the shaft of the humerus and of the femur, and successful 
cases are also reported by Holmes, Cheever, and many other sur- 
geons. Petersen reports the case of a sailor, seventeen years of 
age, who had been suffering for eight days from osteomyelitis of 
the clavicle. The entire diaphysis was dissected by pus and was 
removed. The bone was renewed in four weeks, and the wound 



INFECTIVE INFLAMMATION. 213 

was healed six weeks after the operation. In the bones of the 
extremities such a condition would be, according to Oilier, 
extremely unfavorable for the repair of bone, and if the perios- 
teum is dissected off in this way by pus, its osteogenetic elements 
will be destroyed. The cases favorable for resection are those in 
which the periosteum is thick and covered with osseous plates, and 
this condition is found in the later stages of the disease. Certain 
portions of the skeleton are more readily reproduced than others ; 
as, for instance, the lower jaw and the lower portions of the tibia. 
The prognosis of resection is most favorable in children; after the 
twentieth year resections of the shaft are problematical. In many 
cases in which the operation has been attempted the amount of 
shortening of the limb has been excessive. In resections of the 
shaft of the bone care should be taken not to interfere with the 
epiphyseal cartilage. The incision through the periosteum should 
carefully be made, and this membrane should be bruised as little 
as possible during its separation from the bone. The edges of the 
periosteum should subsequently be sutured with catgut, and a small 
drain of gauze should be left in one or in both ends of the incision. 
The limb may then be immobilized on a splint during the subse- 
quent treatment. By far the greater number of cases of this dis- 
ease come under the notice of the surgeon during the stage of 
necrosis ; that is, after all acute symptoms subside and a fistulous 
opening remains to mark the site of the abscess. 

It is generally agreed that sufficient time must be allowed to 
elapse for the sequestrum to separate from the live bone before the 
attempt is made to remove it. It is quite difficult to determine 
where the line of demarcation is to form, and it often happens that 
a piece of bare bone of considerable size is gradually covered over 
by granulations and the wound heals without any loss of bone. The 
bone receives its nourishment from the vascular medulla, as well as 
from the periosteum, and the separation of the latter does not there- 
fore necessarily result in death of the bone. An early interference 
may therefore not only involve the removal of a needlessly large 
quantity of bone, but may also disturb the vitality of the sur- 
rounding bony tissue and cause the separation of new portions of 
the bone. 

The time required for the separation of a sequestrum varies 
greatly. At the epiphyseal line the bone may separate in a few 
weeks, but in the shaft of the long bones it may be several months 
before the sequestrum is fairly loosened. A fragment of cortical 
bone usually separates much more rapidly than some of the deep- 



214 SURGICAL PATHOLOGY AND THERAPEUTICS. 

seated, spongy sequestra. There is less danger of spontaneous 
fracture if the sequestrum is allowed to remain until the involucrum 
has developed and sufficient new bone has thus been formed to 
replace the old. 

Usually, when a typical case of necrosis presents itself for treat- 
ment, the sequestrum is found deeply seated within a cavity formed 
by new bone, which has grown exuberantly and lines for some dis- 
tance the walls of the sinus leading to the dead bone. When a 
considerable quantity of periosteum has been destroyed by the sup- 
purative process, the dead bone will be found uncovered by new 
bone, and may, consequently, much more easily be reached. The 
cicatricial tissue about it, however, is dense and unyielding, and in 
any case, therefore, free incisions are necessary to lay bare the for- 
eign substance which is to be removed. One should always be pre- 
pared, therefore, for a long and tedious operation and for extensive 
dissection in these cases; for it is not only necessary to remove the 
dead bone, but the cavity must be so treated as to heal permanently. 
The rigid walls of an old involucrum cannot shrink together, and 
they are covered with feeble granulations which may contain a 
miscellaneous assortment of bacteria. These are the conditions 
which favor the persistence of a " bone-fistula." The old method 
of treatment, which consisted principally in fishing for fragments 
of dead bone with the forceps, cannot too strongly be condemned. 
Modern surgery demands a completed operation; that is, one which 
ensures rapid and permanent healing of the wound. 

The limb having been thoroughly cleaned and the sinus having 
been syringed out with some mild antiseptic for several days before 
the operation, an antiseptic dressing should be applied, so as to 
diminish as much as possible the septic condition of the parts sur- 
rounding the wound. The Esmarch bandage having been so 
adjusted as to render the limb bloodless, the sinus should be laid 
open to its point of entrance into the bone. In some cases it will 
be found impossible to do this, owing to the tortuous nature of the 
canal and to the presence of a large vessel or a joint-cavity in the 
immediate neighborhood. In necrosis of the lower portion of the 
diaphysis of the femur the sinus often opens through an intermus- 
cular space near the route of the femoral vessels, and the surgeon 
must proceed cautiously to avoid wounding these vessels. It may 
be more convenient under these circumstances to approach the 
bone-cavity from the opposite side of the thigh if it be necessary 
to chisel away a large surface of new bone. A clean and straight 
incision should be made through the soft parts and the periosteum, 



INFECTIVE INFL. I MM A TION. 215 

and the surface of the bone should be exposed freely. The entire 
roof of the suppurating cavity should then be removed with the 
trephine or the chisel or with both. This operation is necessary 
not only to ensure complete removal of the sequestrum, but also to 
expose the lining pyogenic membrane, so that it may be scraped 
away thoroughly and nothing but healthy tissue be left behind. 
The same scrupulous care should be given to this part of the 
operation that the dentist employs in treating a carious cavity 
in a tooth. The wound, as now shaped, is no longer a fistulous 
tract, but a trough-shaped affair with a large opening. It may 
now be treated so as to heal by granulation or to unite by first 
intention. In the former case the wound, after being thoroughly 
irrigated with a weak solution of corrosive sublimate to wash 
out all particles of bone or of tissue, is stuffed with iodoform 
gauze, which is used in sufficient quantity to keep the upper por- 
tions of the lips of the wound well separated from one another, so 
as to allow the wound to heal slowly from the bottom to the sur- 
face without resuming a fistulous shape. This method consumes a 
considerable period of time, and may, owing to neglect on the part 
of the patient, terminate in a fistula which may require months to 
heal. 

Attempts have been made to hasten the healing process by plas- 
tic operations. Flaps of skin have been turned into the long gut- 
ter, so that the exposed surfaces of bone may be covered in by the 
yielding soft parts. Fragments of bone still adhering to the peri- 
osteum have been loosened from the sides of the trough, and have 
been pushed in so as to obliterate the cavity. 

Schede proposed to fill up this deep cavity in the bone with 
blood-clot, which subsequently becomes "organized," after the 
manner originally described by Lister. The wound must be made 
absolutely aseptic by chiselling away all diseased or infected bone 
and cutting away edges of skin and tissue which have been satu- 
rated for a long time with the discharges. Any suspicious corners 
must be swabbed out with strong solutions of carbolic acid or of 
permanganate of potash, and the wound must be drenched and 
scrubbed freely with milder antiseptic washes. The edges of the 
periosteum and integuments are now approximated by sutures, 
which should be made of catgut and be applied as buried sutures. 
A small strip of protective or rubber cloth is placed over the wound, 
and before the tourniquet is removed an antiseptic dressing is firmly 
bound on, to prevent the escape of blood which oozes from the 
walls of the wound and fills the cavity. This dressing should 



2l6 



SURGICAL PATHOLOGY AND THERAPEUTICS. 



not be disturbed for two weeks, at the end of which time, in 
successful cases, the wound will be found to have healed by first 
intention. 

It is not always easy to retain sufficient blood in the cavity thus 
prepared to fill it completely, in which case the delicate clot grad- 
ually melts away as granulation tissue forms, and the wound has to 
be reopened and allowed to heal from the bottom. A partial suc- 
cess will, however, shorten considerably the healing process. 

Senn conceived the idea of utilizing decalcified bone-chips as a 
' ' filling ' ' for these bone-cavities. These bone-chips are preserved 
in an alcoholic solution of corrosive sublimate or in a solution of 
iodoform in ether. The most favorable cases for this method are 
bone-defects due to the removal of tumors, or bone-lesions other 
than those produced by pus-cocci. The next most favorable cases 
are primary circumscribed inflammations in the epiphyseal ends of 
long bones. This method is also applicable after operation for 
necrosis. After the cavity has been disinfected and dusted over 
lightly with iodoform the chips, previously washed in an antiseptic 

solution, are dried upon a gauze 
compress, and are then put into 
the cavity until it is packed with 
them as far as the periosteum. 
The periosteum is now sutured 
with absorbable buried antisep- 
tic sutures. Buried sutures may 
also be used for the soft parts 
above. The skin is finally su- 
tured with silk. An absorbable 
antiseptic drain of catgut is used 
at the extremity of the wound 
to allow the escape of the super- 
abundant blood, which flows in 
as soon as the tourniquet is re- 
moved. The remaining blood 
coagulates and forms a matrix 
in which lie the bone-chips 

(^g. 43). 

A voluminous antiseptic 

dressing should be applied to 
the limb, which should be con- 
fined in a splint, and the dressing be allowed to remain undis- 
turbed for two weeks. Rest should be enforced until the process 




Fig. 43. 



•Healing of Blood-clot, and Senn's 
Bone-chips. 



INFECTIVE INFLAMMATION. 217 

of repair in the interior of the bone has been completed, embracing 
a period varying from four weeks to three months. 

Many successful cases testify to the value of both the above meth- 
ods. They cannot, however, be carried out in difficult cases except 
by the trained surgeon with every possible convenience at his com- 
mand. Many bone-cavities communicate with the exterior surface 
by numerous tortuous channels, whose walls contain septic material 
which is sure to contaminate the blood-clot. These methods are 
better adapted to cavities not made by suppuration or to pus-cav- 
ities of limited size and readily accessible to the gouge or to the 
curette. In some of the more complicated cases of necrosis a pre- 
liminary operation might so far restore the neighborhood to a 
cleanly condition that the blood-clot method might later be 
adopted with success. When, however, the cavity has been opened 
and cleansed in the thorough manner already described, there is 
every reason to hope that a permanent healing of the wound may 
be completed by the process of granulation in from three to four 
months' time, and this is the method the writer would recommend 
in the majority of cases. The attending physician should never 
undertake the care of such a case if he contemplates only halfway 
measures. If not prepared to go through with the labor of a com- 
pleted operation, it will be better for his reputation to have nothing 
to do with the case. 



IX. THE PROCESS OF REPAIR. 

Formerly the changes brought about in the tissues by means 
of which repair was effected were supposed to be caused by inflam- 
mation. It was thought that a smart inflammatory reaction was 
necessary to glue the lips of a wound firmly together. Aseptic 
surgery .has demonstrated the error of this view, and it is now 
known that the two processes are quite independent of each other. 

The action of the cells in repair is a question about which there 
has been a great deal of dispute. Some of the changes which they 
undergo during inflammation have already been considered. Suf- 
fice it to say here that Virchow adopted the view that the large 
number of new cells seen during the reparative process were 
formed by a proliferation of the pre-existing cells of the part. 
Cohnheim set aside this view, and replaced it by his theory of 
the action of the leucocytes, which were supposed to supply all 
the material for the new tissue that was formed. This theory held 
sway for nearly two decades, but a more perfect knowledge of the 
histology and the physiological action of cells has partially 
restored to the fixed cells of the tissues their former prominence 
in the process of repair. The old theory of cell-proliferation 
assumed that all cells' underwent what is now understood as 
direct cell-division; that is, a segmentation of the nucleus having 
taken place, there was a division of the protoplasm by means of 
which two cells were formed. 

The theory of indirect cell-division s or karyokinesis, has now 
supplanted that of direct cell-division, which is supposed to take 
place only in those cells having no power to form new tissue, such 
as the leucocytes, the role of which in repair is now regarded as 
quite subordinate. One of the earliest changes that is seen in the 
cells of a part when repair is going on is an increase in their size. 
At the same time peculiar changes are taking place in their nuclei. 
The nucleus consists, according to Ziegler, of a membrane and 
contents. The latter is composed of a network of nucleoli, gran- 
ules, and threads which are somewhat opaque, and which can read- 
ily be stained by pigments. This network lies imbedded in a soft 
material which is incapable of receiving color. During the process 

213 



THE PROCESS OF REPAIR. 219 

of division the network of the nucleus undergoes a series of typical 
changes of form which give origin to the term karyokinesis (xd t ouov } 
nucleus ; xiuyaet;, movement) (Fig. 26). Flemming uses the term 
karyomitosis (jjuto^ a thread), denoting the thread-like appearance 
of the network. That portion of the material of the nucleus 
which stains readily is called "chromatin." 

The nucleus, in fact, is a highly organized substance by which 
the cell transmits its peculiarities to its descendants. The proto- 
plasm of the cell is the medium of communication with the sur- 
rounding tissues, and it regulates the nutrition. 

When the cell is about to undergo division there is a marked 
increase in the amount of chromatin of the nucleus ; the threads 
of the network become much thicker, and they seem to be coiled 
loosely together; at the same time numerous nodules appear in the 
network (Fig. 26 1 ). The nucleolus now disappears, and the mem- 
brane of the nucleus, losing its ability to take the staining fluid, is 
soon lost (Fig. 26 2 ). The threads become gradually thicker, and 
arrange themselves in a series of loops which point toward the 
equator of the nucleus, and form, when seen from the poles, a 
stellate figure known as the mother-star (Fig. 26 s ). 

The next change in the grouping of the threads is known as 
metaki?tesis, and consists in a movement by which these loops are 
gradually turned around so as to point toward the poles of the 
nucleus. As the loops which are now found in two separate 
groups gradually approach the poles, there are formed two stellate 
figures (one near each pole), which are known as daughter- stars 
(Fig. 26 4 ). Their stellate appearance is well seen when viewed 
from the poles. These daughter-stars gradually resume the thread- 
like coils found in the original nucleus, and eventually form a 
network. x\t the same time a new membrane is formed around 
each coil (Fig. 26 5 ), and two nuclei are thus developed (Ziegler). 
During nuclear division the protoplasm of the cell undergoes certain 
active rotary movements : as the result of these movements there is 
the formation of a bright zone around the nucleus and of radiating 
lines at the poles of the cell. Finally, there is a segmentation of the 
protoplasm of the cell, which segmentation begins about the time 
the daughter-coils are formed. Considerable variations may take 
place in nuclear division, but the above is the type of the process. 

The division of the nucleus is usually bipolar, but it may be 
multipolar. In this way many nuclei may form. If the segmen- 
tation of the protoplasm is delayed or if it does not occur, the large 
many-nucleated cells known as giant-cells are developed. 



220 SURGICAL PATHOLOGY AND THERAPEUTICS. 

The cells that multiply and take part in the formation of new 
tissue are the fixed cells of the connective tissue and the cells 
forming the walls of small blood-vessels, which cells also take an 
active part in this process. Under these circumstances the endo- 
thelial cell is seen much enlarged, projecting into the lumen of the 
vessel and undergoing mitosis. Some of the new cells come from 
a distance, and belong, therefore, to the variety of wandering cells. 
The leucocytes wandering into the part are frequently present in 
large numbers, particularly when there is much inflammation, but 
play no active part in the formation of new tissue. 

While these new cells are collecting the old tissue has perhaps 
softened and broken down. The intercellular substance becomes 
more or less granular, and less is seen of it. In this way there is 
formed a new temporary tissue, known as granulation or embry- 
onic tissue. The cells found here are the leucocytes, single-nucle- 
ated or polynucleated, and the cells which are actively forming 
new tissue are called "formative cells," "embryonal cells," or 
"plasma cells." They have a granular protoplasm and a bright, 
round, and large nucleus, which stains readily, giving the cell an 
appearance strongly suggestive of epithelium. They are therefore 
usually called ' ' epithelioid cells. ' ' Owing to their power to form 
connective tissue they are also called "fibroblasts." They have 
various forms : some are spindle-shaped, others pear-shaped, and 
many may have several prolongations. 

Ballance and Edwards describe the plasma-cells seen in small glass 
chambers placed beneath the skin of animals, according to Ziegler's 
method, as mostly plate-like cells extended into so thin a film that their 
exact limit was hard to determine. They were distinguished from leucocytes 
by their larger size and coarser granules and by the constant presence of a 
single clear nucleus of oval figure. In specimens from chambers that had 
rested sevent3 T -two hours these cells showed vacuolation. In some of these 
vacuoles a leucocyte or red corpuscle could be found. The leucocytes near 
these cells appeared to serve as a pabulum for them. Not all the leucocytes 
were disposed of in this way : some of them were dissolved in the tissue- 
plasma exuded by the plasma-cells (a protolytic ferment). 

Grawitz believes that many cells — his so-called "slumbering 
cells" — develop from fibres: nuclei first appear within fibres, and 
the cell-body is gradually formed around them. These cells are 
capable of division like fixed cells, and when cicatrization takes 
place they pass into their fibrous condition again and become 
slumbering cells once more; that is, they now no longer react to 
staining processes. 

When connective tissue is formed, there is seen between these 



THE PROCESS OE REPAIR. 221 

slumbering cells a more or less homogeneous intercellular sub- 
stance in which fibrillar later make their appearance. The fibril- 
Ice, however, may form directly without the intervention of a 
homogeneous material. According to some observers, these fine 
fibres are formed by a splitting up of the protoplasm of the cell 
itself: other observers, however, assume that an intercellular sub- 
stance is exuded, as it were, from these cells, and that in this 
medium the fibrils are subsequently formed. When the develop- 
ment of fibres has reached a certain point the formative cells or 
fibroblasts begin to diminish in number, those which are left being 
enclosed in narrow spaces between the bundles of new fibres. 

According to Grawitz, as already seen, the new cells are devel- 
oped from the so-called kk slumbering cells," which lie, undetected 
by staining fluids, in the fibres under ordinary circumstances, but 
when in a state of irritation they become active once more and are 
capable of forming new tissue. This view, though endorsed by 
many, has not met with general acceptance. 

Thus far, connective tissue only has been considered. The cells 
of this tissue, like all other cells, can of course solely produce those 
of their own blastodermic layer. An epithelial cell cannot produce 
cartilage or bone. Some cells have permanently lost their power 
to proliferate, such as the epidermal cells and the non-nucleated 
blood-corpuscles ; also, probably, the ganglion-cells. Epithelial 
cells, gland-cells, connective-tissue cells, periosteal and bone-mar- 
row cells, possess very active reparative properties. 

Attention will now be given to the healing of a wound through 
the skin and subcutaneous tissue. When there is made an incision 
which freely divides these structures, their natural elasticity sepa- 
rates the edges of the wound from one another, and the wound is 
said to "gape/' When only smaller vessels are cut, the bleeding 
either stops spontaneously after exposure to the air or it may read- 
ily be controlled by the temporary application of pressure-forceps. 
When the larger vessels have been tied and the bleeding ceases, 
the edges of the wound are brought together by suture. If the 
wound is deep, it may be necessary to pass some of the sutures to 
an unusual depth, or buried sutures may be applied to bring the 
subcutaneous fatty tissue or muscular fibres into their proper posi- 
tion, so that no " dead spaces M are left. In other words, the walls 
of the wound must be brought in contact throughout, otherwise 
the oozing of blood and serum that almost invariablv occurs during 
the first few hours may separate the walls from one another and 
thus delay the healing process. 



222 SURGICAL PATHOLOGY AND THERAPEUTICS. 

If the wound has been preserved in an aseptic state, there are 
no symptoms of inflammation seen during the healing process. 
The parts appear during the next few days almost exactly as 
they were at the time the wound was first dressed. There is 
usually a certain amount of swelling and tenderness in the part. 
The former symptom is due to the exudation of serum, which 
collects in the interstices of the tissue or between the lips of the 
wound. In large wounds the amount of serum thus exuded may 
be considerable. It is estimated that the quantity of serum which 
flows from the wound of an amputated hip-joint may exceed a pint 
in the first twenty-four hours. There is also an increased number 
of cells in the part, and a deposit of fibrin both in the lips of the 
wound and in the interstices of the tissue. In consequence of this 
exudation the parts immediately about the wound are somewhat 
firmer to the touch than they were before. 

Firm pressure and careful adjustment of the edges of the wound 
will generally greatly diminish the amount of the exudation. The 
dressing, however, is usually soaked with a sero-sanguinolent dis- 
charge during the first twenty-four hours. On this account some 
surgeons still prefer to place a drain of some kind between the 
edges of the wound for twenty-four or forty-eight hours, even 
though they are quite confident of its aseptic character. The 
primary oozing of serum is thus disposed of, and undue pressure 
on sensitive or on vital parts, such as the brain, is avoided. A 
small strand of sterilized gauze or a thoroughly sterilized drainage- 
tube is sufficient for the purpose. If the drain is not removed 
before the end of the second day, it is liable to cause suppuration. 
Even though the dressing be perfectly aseptic, the staphylococcus 
epidermidis albus (existing in the deeper layers of the epidermis) 
may thus find its way into the interior of the wound. 

If the stitches are removed on the fifth day in wounds where 
there is no tension, the skin will remain adherent, although the 
union is still far from firm. The edges of the wound are, in fact, 
only glued together during the first two or three days by the 
coagulated fibrin. 

In large wounds coaptation of the parts on the surface is rarely 
so perfect that complete union of the edges of the skin takes place 
from one end of the wound to the other. At one point the skin 
may be at a slightly lower level than at another point, or the skin 
may be curled in by the stitches. Small fragments of skin may 
have been bruised or unduly constricted, and minute sloughs may 
form in this way. Consequently, after the dressing has been 



PLATE II 







- 



) i 










■ ■);■:■■■ 






■ ■:'■'' 










.vs^- 



Zo 






'■' * 




Healing by First Intention of an Abdominal Wound (sixth day) : above is seen a suture mfil 
trated with leucocytes; below are seen the edges of a divided Iinea alba separated by a 
blood-clot; upper border, skin ; lower border, peritoneum. Cell infiltration is seen only 
ahmg the line of incision. 



THE PROCESS OF REPAIR. 223 

removed minute scabs are found here and there along the line 
of the incision that do not drop off for several days. The points 
of exit of the suture are also marked by small crusts. During this 
period the wound is in a very receptive state, and any undue strain 
or neglect may favor the development of a minute focus of sup- 
puration under some one of these scabs, which may result in an 
abscess. The soft new tissue has feeble power of resistance to the 
invasion of the bacteria. A large wound cannot be said to have 
passed through its period of danger before the end of three weeks. 
This mode of union is termed healing by first intention (PI. II.). 

If the wound has not been kept aseptic, symptoms of inflamma- 
tion appear on the second day. The edges of the wound are some- 
what reddened, and much more tender than in the aseptic wound. 
By the third day a slight amount of pus may emerge from some 
portion of the superficial structures or from a stitch-hole. A mod- 
erate amount of sepsis will not interfere with a prompt healing of 
the wound, and if a moist antiseptic dressing is applied to favor 
the escape of the small quantities of pus found here and there, the 
wound may practically heal by first intention. In such wounds, 
however, it is probable that there will be left a small sinus which 
may not heal until the end of two or three weeks. 

If sections of the wound, made at different stages of the heal- 
ing process, are now examined, the following appearances will be 
observed: At the upper margin of a wound two or three days old 
the epidermis is usually found more or less curled in. Wherever in 
the deeper layers of tissue the fibres have retracted, there are found 
small clots of blood, which serve the useful purpose of filling out 
all irregularities. If the section has been stained carefully, all 
cell-structures stand out with great distinctness, and the line of 
the incision is indicated, even with a very low power, by a row of 
cells which have accumulated at the edges of the wound on either 
side. 

In cases running an aseptic course the number of cells is com- 
paratively small, and they are not seen except in the immediate 
vicinity of the wound (PI. II.). There is an accumulation of 
cells around some of the blood-vessels, and rows of small round 
cells may be seen extending between the bundles of fibres toward 
the margins of the wound. The small clots found in clefts 
between retracted fibres are invaded with numerous leucocytes. 
The number of vessels does not appear to be increased, and it is 
probable that in many instances the formation of numerous vascu- 
lar loops, so often described, does not take place. 



224 SURGICAL PATHOLOGY AND THERAPEUTICS. 

In healing by first intention there is at first no reddening of the 
cicatrix, which, however, becomes red and prominent at the end 
of a few weeks, and it is probable that at this period new vessels 
have formed. In many parts of the body the scars are almost 
imperceptible from the beginning, and in these cases there is little 
if any increased vascularity. According to Thiersch, the plasma- 
canals communicating directly with adjacent vessels contain blood, 
by which the tissues are provided with nutriment until new blood- 
vessels are formed. When there is considerable amount of inflam- 
mation complicating the healing process, there is a formation of 
new vessels, which develop in the shape of loops projecting toward 
the edges of the wound. Experimentally it has been shown that 
in animals these vascular loops may unite across the lips of the 
wound in about ten days. 

A careful inspection of several sections usually discloses the 
fact that minute fragments of the edge of the wound or of the 
deeper structures have become necrosed and are in process of 
absorption. The leucocytes are markedly increased in numbers 
around such masses, and also around fragments of the ligature, 
between the fibres of which many cells make their way. It is 
evident that the leucocytes are endeavoring to break up and absorb 
all material that is in the nature of a foreign body (PI. II.). 

If a wound is examined near the end of the first week, it will 
be found that the round cells are beginning to disappear, and in 
their place will be seen spindle-cells or fibroblasts. These are the 
cells which have developed from the pre-existing cells of the part. 
The surrounding cells or leucocytes take no prominent part in the 
process of repair, but serve as nutriment for the forming tissue. 
Between the fusiform cells new intercellular substance is developed 
in the way already indicated, and thus new fibrous tissue is formed. 
As the fibres develop many of the fusiform cells undergo granular 
degeneration and are absorbed. The same fate also awaits such 
leucocytes as have not already found their way through the lymph- 
channels back into the circulation. In this way is formed cica- 
tricial tissue, which differs from normal fibrous tissue in that the 
fibres do not run parallel with one another, but interlace in various 
directions, forming a felt-like mass which is very elastic and has 
great contractile power — a peculiarity which serves a useful pur- 
pose in drawing the edges of the wound firmly together. The scar 
when gradually formed becomes prominent and red, and is a source 
of disfigurement on an exposed surface. The contractile nature 
of the scar-tissue, however, gradually constricts, one after another, 



THE PROCESS OF REPAIR. 225 

the delicate capillary loops that have developed, so that eventually 
there is less blood flowing through the part than there was before 
the injury. This change takes place slowly, and a year or more 
may elapse before the red scar has faded away and given place to a 
line that is somewhat paler than the surrounding healthy skin. 

Healing by second intention occurs when the edges of the wound 
have not been brought together. In this case a considerable 
quantity of new tissue is formed, by means of which the cavity is 
built up from the bottom. If a w r ound is made (by the removal of 
a breast) so large that the skin cannot be brought together, it will 
be found, after the bleeding has been arrested, that in the portion 
which has not been closed the bottom is covered by the red muscu- 
lar tissue of the pectoralis muscle, and that the sides are composed 
of the yellow adipose tissue. The anatomical structures are some- 
what obscured by the formation of a thin coagulum of blood which 
fills out the irregularities of the surface on the bottom and around 
the edges of the wound. After the lapse of several hours a trans- 
parent film forms over the whole surface, covering it like a varnish. 
The wound is said to have "glazed." This appearance is pro- 
duced by the exudation of serum from the blood-vessels and by the 
coagulation of the fibrin it contains. Formerly surgeons were in 
the habit of waiting for this stage of the healing process before 
closing the wound, as it was supposed that the opposing surfaces 
would then quickly adhere and would not be forced apart by the 
exudation of serum. 

This film does not remain transparent a long time, for soon 
minute opaque spots begin to appear here and there, caused by the 
accumulation of leucocytes. The coagula of blood on the surface 
also soften, and the color runs through the transparent layer and 
stains it a dirty red. The normal tissues now begin to disappear, 
and the layer formed over them soon becomes further discolored 
by the liquefaction of minute sloughs of tissue which have been 
bruised by the knife. The surface of the wound no longer has its 
clean appearance, but it is covered with a dirty membrane having 
a mixture of ill-defined colors. This membrane remains for three 
days, at the end of which time it appears to have separated from 
the subjacent parts by the formation of a fluid beneath. The mem- 
brane finally floats off with a free flow of pus, and there is disclosed 
a layer of bright-red tissue studded with very minute elevations, 
known as granulations. The wound is said to have cleaned off. 
It will be noticed at this stage that the wound is much shallower 
than it was before. The tissue of which these granulations are 

15 



226 



SURGICAL PATHOLOGY AXD THERAPEUTICS. 



composed is known as granulation tissue, and it is by the growth 

of this tissue that the cavity is filled. In a few days this layer 
reaches the level of the surrounding skin, and it is now seen that 
the area oi the wound is smaller than it was at the beoqnnincr 
The next stage in the healing process is the covering of the granu- 
lations with epidermis. If the margins of the granulating tissue 
be examined with a lens, the presence will be noted of a trans- 
parent film, through which the granulations may still be seen, 
although they have flattened out. As this transparent film works 
its way toward the centre of the wound the older layers change 
to a pearly-white color and become opaque. This process (Fig. 44 j 




v . 



Fig. 44. — Healing by Second Intention. 



consists in the proliferation of epithelial cells, by which means the 
new granulation tissue is eventually covered over. These cells can- 
not form independently in the centre of the wound, although the 
new epithelial cells possess amoeboid movements and may wander 
a short distance from the margin of the wound. The growth is 
not unlike the formation of ice on a pond, the water around the 
edo-es of which first becomes covered by a thin film of ice, which 
by a process of continuous formation finally covers the deeper 
waters at the centre. 

In large wounds the surrounding epidermis is unable to supply 
a sufficient number of cells to cover the open surface; consequently, 
the wound would not heal were it not for the power of the cica- 
tricial tissue forming beneath the granulations to contract and 
draw the edees of the wound toward one another. This contrac- 
tile power is caused by the shrinkage due to the absorption of the 



THE PROCESS OF REPAIR, 



227 



soft cellular and vascular granulation tissue and its replacement by 
dense fibrous structures. 

If the granulation tissue is studied under the microscope, there 
will be found a tissue crowded with small round cells and contain- 
ing a large number of small blood-vessels, which tend to run in a 
vertical direction toward the surface of the wound. An examina- 
tion of this tissue with a high power of the microscope shows that 
there are not only a large number of leucocytes, distinguished by 
their numerous nuclei which come out very characteristically 
when stained, but that there are also many single-nucleated leu- 
cocytes and larger epithelioid cells. Near the surface of the gran- 
ulation tissue the leucocytes abound (Fig. 45). L,ower down are 










'o n o 



ffi 



Fig. 45. — Vascular Spaces with Tissue filled with Leucocytes near the Surface of Granulations. 



found the larger cells, particularly in the vicinity of the blood- 
vessels, from whose walls an active cell-growth appears to take 
place. Still lower, the cells assume a spindle shape, and the deep- 
est layers of all consist of bundles of spindle-cells running in a 
horizontal direction beneath the surface. In wounds that have 
remained open for a long time or in ulcers this deepest layer has 
become quite fibrous, and it seems to serve the purpose of walling 
off the surrounding healthy tissues from the imperfectly-formed 



228 SURGICAL PATHOLOGY AND THERAPEUTICS. 

tissue above, which in many cases contains the elements of disease 
(Fig. 46). 

Many observers describe a rich growth of blood-vessels, arranged 
in festoons and loops, running vertically toward the surface, and 




Fig. 46. — Detail Study from a Deep Layer of Granulation Tissue, showing a vessel with 
epithelioid cells and spindle-cell growth. 

ascribe to the presence of these loops the little hillocks of cells so 
characteristic of granulations ; but a study of microscopical sec- 
tion does not show this arrangement. The blood-vessels are com- 
paratively few in number at this time, though they are much 
larger than those found in the surrounding parts. They have a 
tendency to ascend, either vertically or at a slight angle, toward 
the surface, where their further progress is lost. They are parallel 
with one another, and probably anastomose by a more or less hori- 
zontal system of capillaries in the upper layers of cells. (Fig. 44.) 
The histological changes which occur during the formation of 
granulation tissue have already been indicated so far as the action 
of the cells is concerned. There is seen at first, as the result of 
this action, an abundant small round-cell infiltration of the part 
occupying nearly all the space, so that the intercellular substance 



THE PROCESS OF REPAIR. 229 

is difficult to find. The fibres have, in fact, undergone a soften- 
ing, and the intercellular substance appears as granular "material. 
The majority of these cells are leucocytes which have emigrated 
from the blood-vessels ; but many of them, principally those with 
single nuclei, are derived from the pre-existing cells of the part. 
As this tissue develops and as the cavity begins to fill, there is 
found, in studying with high powers, a great variety of shapes, 
some being club-shaped, others having a large body and a bright 
oval nucleus, the so-called "epithelioid cells." The epithelioid 
cells may be seen best near the vessels which ramify in the new 
tissue, and they are the principal cells relied upon for the formation 
of the new scar-tissue. In the deeper layers, consequently among 
the cells most advanced in development, are found many spindle- 
shaped cells running parallel with one another and in a more or 
less horizontal direction. This is the next stage of the process. 
It is between these cells that the new fibrillar are seen forming. 
On the surface are found numbers of broken-down cells and poly- 
nucleated cells enclosed in a coagulated material. This is the 
liquefied tissue cast off from the upper layer and seen on the liv- 
ing granulations as pus. 

The new blood-vessels form by a budding growth from the walls 
of pre-existing vessels. The endothelial cells of a capillary undergo 
division by karyokinesis, and presently there is seen a tent-like ele- 
vation (from the wall of the vessel) that continues to grow into a 
fine prolongation, consisting of granular protoplasm, which, after 
a certain length of time, contains nuclei (Fig. 47). This bud 
may unite with a similar one, or may return to the vessel again, 
forming a vascular loop, or may communicate with another ves- 
sel (Fig. 48). The vessel may also terminate in a club-shaped 
end. The central portion of the new protoplasm now begins to 
soften, and a cavity forms which subsequently communicates with 
the lumen of the vessel. The new tube at first has a homogene- 
ous wall, but later the protoplasm groups itself around nuclei that 
are forming, and endothelium is thus developed. Some of the tis- 
sue-cells of the neighborhood come in contact with, and strengthen, 
the vessel-wall. When the vessels are in a state of development 
like this their walls are highly cellular. In all granulation tissue 
an active cell-growth is found near the vessel, and the endothelium 
of the capillaries has a special reputation for its power of procrea- 
tion. This is the method of intracellular growth of capillaries > 
and is the generally-accepted theory of vascular development. 

The intercellular method of growth is seen in the formation of 



230 SURGICAL PATHOLOGY AND THERAPEUTICS. 

a bundle of spindle-shaped cells in new tissue in which vessels are 
also forming. Some of these cells group themselves together, and 
form a channel which presently communicates directly with the 
vascular system. If these channels are traced carefully, the ex- 




Fig. 47. — Development of Blood-vessel in Mesentery of an Embryo. 



treme limits may be found to which the corpuscles have pene- 
trated. Inasmuch as it is known that the plasma-canals are filled 
with blood in fresh wounds, it is highly probable that the subse- 
quent cell-growth can form canals which open into the blood-ves- 
sels. In the writer's studies in the repair of arteries new tissue 
has been seen growing into a portion of a blood-vessel which has 
been cut off from a trunk by a double ligature, containing young 
vessels developing in this way. In sections of granulation tissue 
can be seen small blood-vessels with bands of cells branching off 
from their walls. In the axis of these bands the cells are separated 
and vessel-walls are formed from them. 

When the granulation tissue has been covered with epidermis, 
the cell-infiltration has already in part disappeared, and the poly- 
nuclear leucocytes have broken up and have been absorbed. The 
fibroblasts have formed intercellular substance. Perhaps some of 
the fibroblasts have been transformed into fibres to awaken once 
more at some future time. At all events, the scar-tissue now be- 
comes very rich in fibres, and few cells are seen there. The blood- 



THE PROCESS OF REPAIR. 



231 



vessels, which at first are quite numerous, and which give the cha- 
racteristic redness to the new cicatrix, eventually diminish very 



{ 1 




Fig. 48. 



-Development of Blood-vessel in Mesentery of an Embryo : formation of 
vascular loops. 



greatly in number in the way already indicated, and the scar 
becomes paler than the normal skin; but this change does not 
occur until months after the wound has healed. 

The healing of a wound whose edges have not been brought 
together may take place without the formation of pus, provided 
the cavity thus formed is filled with healthy blood-clot and the 
wound itself is in an aseptic condition. 

The so-called organization of the blood-clot occurs by an in- 
growth of cells into the gelatinous material thus furnished, which 
material takes no active part in the process, but serves as an admir- 
able "culture-medium" for cell-development. In such cases at 
the end of two or three days the clot is seen filled with a round- 
cell infiltration, the cells of which grow more numerous as the 
clot breaks up and disappears. The granulation tissue thus formed, 
in a few days more is supplied with blood-vessels. If no suppura- 
tion takes place, a portion of the old clot remains as a scab upon 
the surface until cicatrization is complete. The organization of 
the clot is not, however, always effected in this way. In some 
cases the clot may recede before the advancing cell-growth, which 



232 



SURGICAL PATHOLOGY AND THERAPEUTICS. 



occurs in the shape of granulations projecting in an irregular 
manner into it in the same way as upon a granulating surface. 
The clot shrinks greatly as the new tissue grows forward to take 
its place (Fig. 49). This method of healing by blood-clot occurs 
in subcutaneous wounds, in simple fractures, in ruptures of inter- 
nal organs, and, in fact, to a certain extent, in almost every wound 
that heals without suppuration. 

The granulating surfaces of open aseptic wounds (a few days 
old) may be brought together, and will unite by third intention. 






vT& 




Fig. 49. — Granulations compressing Blood-clot; injected specimen (tenth day). 



In older open wounds with moist and luxuriant granulating sur- 
faces the granulations should be scraped off before bringing the 
edges together. In this way the healing process is sometimes 
greatly shortened. 

The healing of tendon varies somewhat according to the presence 
or the absence of blood-clot. After the tendo Achillis has been 
divided experimentally in the rabbit, the sheath is found filled with 
a firm cylindrical clot. A few days later it will be evident that a 
growth of new tissue has taken place in the tendon-sheath, and 
that a callus has been formed enclosing the retracted ends of the 
tendon (Fig. 50). If the specimen is now removed, placed in alco- 



THE PROCESS OF REPAIR. 



233 




hoi to harden, and subsequently is divided longitudinally, it will be 
found that the divided ends of the tendon have retracted consider- 
ably, leaving between them a mass of blood-clot and new tissue which 
forms a spindle-shaped covering enclosing 
both ends for some distance beyond the 
point of division. The clot is already par- 
tially absorbed, and the new tissue is grow- 
ing into it in various directions. If the 
limb has previously been injected with Ber- 
lin blue, the rich new formation of vessels 
may be seen producing a highly vascular 
network around the borders of the clot. In 
such a case as this the ordinary method of 
the organization of the blood-clot has not 
taken place, owing probably to the size of 
the clot, but the tissue has formed granula- 
tions which are pushing into the clot. It is 
probable that large clots are usually ab- 
sorbed in this way by lateral pressure, 
rather than by infiltration with wandering 
cells. If the new-formed tissue be exam- 
ined at this time with a high power, it will 
be found to consist of spindle-shaped cells 
running mainly in a direction parallel with 
the long axis of the tendon. The new tis- 
sue appears to spring from the inner wall 
of the sheath, while the cut edges of the tendon, standing out 
in bold relief, seem to take no part in the process. The new 
blood-vessels form about from the tenth to the fourteenth day a 
rich vascular network in the provisional tissue, and some of 
them can be seen already communicating with vessels lying 
between the fibres of the old tendon (Fig. 51). In the granula- 
tions which surround the margins of the blood-clot there is found 
a rich anastomosing network of vessels, many of them form- 
ing loop-like prolongations; others seem to terminate in club- 
shaped extremities (Fig. 49). The blood-corpuscles of the clot 
have by this time disappeared, having become pressed together, 
and the clot now appears as a brownish mass of tangled fibres of 
fibrin. As the process of repair proceeds the fusiform cells dimin- 
ish in number and the intercellular substance begins to make its 
appearance: this process continues until a tissue is formed which, 
with the microscope, is difficult to distinguish from normal ten- 



Fig. 50. — Healing of Ten- 
don : callus formation with 
absorption of blood-clot. 
Granulations are seen com- 
pressing the clot from the 
sides, and, at the lower por- 
tion, from behind (tenth 
day). 



234 



SURGICAL PATHOLOGY AND THERAPEUTICS. 



don-fibre. As this new tissue develops a large portion of the pro- 
visional tissue is absorbed, together with the remains of the blood- 
clot, and the callus disappears. 

When the blood-clot is absent the walls of the sheath come in 
contact, and unite as a band which joins the ends of the tendons. 




Fig. 51. — Detail Study of the End of the Divided Tendon seen in Fig. 50. 



New tissue in many cases grows between these walls, and a tendon- 
cicatri* will thus be formed. 

According to Viering, the tendon-cells also take part in the 
repair, but no change is observed in them before the fourth day. 
All that is seen of the tendon-cells in the quiescent state is an 
elongated staff-shaped or double-oval nucleus bent into a gutter 
shape. There is but little protoplasm to be seen beyond a delicate 
granular mass around the nucleus and along the margin of the 
plasma-canals, on the sides of which lie these cells. The nuclei 
soon enlarge and the protoplasm becomes clearer. Nuclear divis- 
ion next takes place, and the cells soon become mingled with the 
fusiform cells produced by the granulation tissue. Viering also 
found cells which he regards as developed from the so-called 
' ' slumbering cells" in the tendon-fibres. It is probable that the 
tendon-cells take only a comparatively limited part in the process 



THE PROCESS OF REPAIR. 235 

of repair, though the new tissue formed resembles tendon-tissue 
more closely when the ends of the tendon have been sufficiently 
approximated. In some tendons the divided ends are not reunited, 
owing to their great displacement. This is more likely to occur near 
the flexure of joints and where the sheath is lined with endothelium. 
Tendons widely separated may be exposed by an incision and the 
ends may be approximated by sutures. In this case union takes 
place with more or less complete restoration of function. An attempt 
should always be made to suture the divided ends of a tendon if there 
is any probability that spontaneous union will not occur. When a 
tendon is divided intentionally by the surgeon for the purpose of 
lengthening it, the ends may be allowed to remain a considerable 
distance apart in certain localities, as, for instance, the ankle. If 
it is desired to elongate the tendon of the wrist or of the hand, a 
plastic operation should be performed. The tendon in this case 
may be divided by an extremely oblique incision, so that the ends 
will still overlap slightly when considerable retraction of the prox- 
imal portion has occurred. A flap may be made by partially 
dividing one of the ends some distance above the seat of the wound, 
and by incising the tendon along its central axis from this point 
close down to the point of injury. The flap thus formed can be 
reflected and be united to the other end. 

Repair of muscular fibre is a subject about which observers 
have differed greatly. It was formerly supposed that striped 
muscular fibres were not able to reproduce new fibres, and 
that the cicatrix of muscle was connective tissue. More care- 
ful histological study has disproved this view. Differences of 
opinion have, however, prevailed as to the origin of the mus- 
cular fibres. Some authorities believe that the new growth pro- 
ceeds from the muscular cells or sarcoblasts; others assume that it 
originates from the contractile substance which is metamorphosed 
protoplasm. 

Nauwerck has recently made a series of careful investigations to 
determine these various points, by experiments on rabbits. He found 
several preliminary changes which are not permanent. In small 
wounds of muscle at the end of twelve hours evidence of cell-divis- 
ion is seen in the connective tissue of the perimysium internum and 
in the endothelia of the small vessels. The height of the development 
of granulation tissue thus formed is reached about the sixth day. In 
the centre of this tissue necrosed fragments of muscular fibre and 
giant-cells are seen. This new tissue occupies the injured part, and 
extends along the perimysium for some little distance between the 



236 SURGICAL PATHOLOGY AND THERAPEUTICS. 

neighboring healthy muscular fibres. It does not remain long, 
however, and at the end of two weeks there is seen in its place con- 
nective tissue with few nuclei separating some of the muscular 
fibres. In the mean time, the ends of the injured muscular fibres 
break up into spindle-shaped fragments, and some of them undergo 
fatty degeneration, vacuolation, or a vesicular degeneration. Some 
fibres remain at first in contact with their necrosed ends; other 
fibres atrophy and terminate in tapering points. The separation 
of the necrosed fragment is favored by leucocytes and connective- 
tissue cells, and during the next few weeks they are gradually 
absorbed. 

One of the earliest changes seen in the living muscular fibre is 
the proliferation of the muscular cells, or so-called " sarcoblasts, ' ' 
which appear in the form of bundles of muscular cells at the ends 
of the muscular fibres, either near the necrotic zone or some dis- 
tance away. According to Nauwerck, they do not undergo stria- 
tion, as some observers have supposed, but at the end of the first 
week undergo fatty degeneration, and at the beginning of the 
third week have disappeared. There is seen also, at an early 
period, a peculiar longitudinal splitting up of muscular fibres, 
accompanied by an active formation of nuclei, the disappearing 
fibre being replaced by a bundle of slender fibres having longi- 
tudinal striation and spindle-shaped cells. 

About the sixth day some of the living fibres begin to elongate 
and to grow in among the necrosed masses of fibres. The first 
terminal prolongations form narrow fibres composed of a proto- 
plasm rich in nuclei. These outgrowths occasionally surround, 
fork-like, a necrotic fibre. By the eighteenth day the granula- 
tion tissue is already invaded for some distance by the new fibres. 
These prolongations grow from the stumps of old fibres, forming 
the tapering fibres found near the wound, and from fibres which 
have been split up longitudinally. The prolongations are not 
always single: in some places two such growths are seen coming 
from one fibre, and these in turn may bifurcate. Later, these 
new fibres present at their ends club- or spindle-shaped swellings 
which are richly supplied with nuclei. Karyokinesis is seen in 
these nuclei, but more frequently multiplication is effected by 
the process of "indirect fragmentation." These muscular buds 
show a longitudinal striation, but by the end of the second week 
transverse striae are plainly seen. The nucleated terminal por- 
tions present an appearance closely resembling giant-cells. These 
swollen ends disappear during the fifth or sixth week. 



THE PROCESS OF REPAIR. 



*37 



As the muscular fibres grow they lose their parallel arrange- 
ment and becomes entangled with one another. Budding may 
take place, not only from the ends of the fibres, but also laterally. 
The former method is, however, the usual one. The new-formed 
fibres gradually invade the connective-tissue cicatrix. They be- 
come thicker and cylindrical, and acquire transverse striation. 
Many of them do not remain permanently, but break down at 
an early stage of the process and undergo fatty degeneration. 
As the fibres grow from opposite sides of the wound they inter- 
lace with one another (Fig. 52) like the fingers of clasped hands 



£ 



■ ' ' "- - 



*i v 







Fig. 52. — Repair of Muscular Fibre (Xauwerck). 



(Neumann). In this way the connective-tissue scar disappears. 
In small wounds the cicatrix is therefore entirely muscular. In 
large wounds the fibres may be unable to form sufficient new 
muscle, and the connective-tissue cicatrix persists. The great 
irresrularitv in the direction of the new fibres is so modified 
as time goes on that the horizontal arrangement reappears, but 
there is usually more or less interlacing of the new muscular 
fibres. 

Repair of Nerves. — It has now been abundantly proved that 
a spinal nerve when divided can reunite with return of its 



238 SURGICAL PATHOLOGY AND THERAPEUTICS. 

functional activity. It has also been proved that the periph- 
eral end of one nerve can be united to the central end of 
another nerve with restoration of function. As yet there are 
no data which show that a purely motor trunk can unite with a 
purely sensory trunk, with a return of function to the peripheral 
portion. 

Up to the time of Nasse and Waller it was generally believed 
that nerves were united by the formation of new fibres between 
the divided ends, and that the peripheral end suffered no degen- 
eration, union taking place by first intention. This view appears 
to have been borne out by clinical experience in certain cases in 
which, after nerve-suture, there was an immediate return of 
motion or of sensation, or of both. Experimental researches on 
animals, however, have not confirmed this view. The rapid 
reproduction of sensibility is explained in some cases by anasto- 
mosis of the peripheral branches of the divided nerve with other 
sensitive nerves that have not been cut; other cases may be exam- 
ples of the so-called "supplementary " or "vicarious sensibility" 
and motion. The experiments of Howell and Huber, as well as 
those of other observers, show that in animals the peripheral end 
of a divided nerve degenerates completely throughout its whole 
length. There is also a degeneration of the terminal fibres of 
the central end to a limited extent. These degenerated nerve- 
fibres are subsequently replaced, and the repair which unites the 
two ends of the nerve takes place from both fragments, but chiefly 
from a downward growth of embryonic fibres from the central 
portion. 

The new nerve-tissue is produced from pre-existing nerve-tissue, 
and not from the connective-tissue structures which form a com- 
ponent part of the nerve-trunk. New nerve-fibres are conse- 
quently not formed in the granulation tissue surrounding the 
ends of the divided nerve, but the actively-growing embryonic 
fibres from the central and peripheral ends penetrate this tissue, 
and finally meet one another and unite. According to Ranvier, 
Kolliker, and others, the repair takes place from the central ends. 
The axis-cylinders swell and divide into several branches that 
eventually break through the neurilemma and ramify in the con- 
nective-tissue structures which support the nerve-fibres (endoneu- 
rium and perineurium), and cross through the granulation tissue 
into the peripheral end, some of the cylinders eventually finding 
their way into the nerve-sheaths again. In accord with this view 
is the theory that the axis-cylinder is a prolongation of a nerve- 



THE PROCESS OF REPAIR. 



239 



cell, and, when cut off, repair can take place only from the cell 
from which it originated. 

Howell and Hnber found that the return of function in the 
sutured nerve in a dog begins to appear on the twenty-first day, 
and is nearly perfect at the end of eleven weeks. This return of 
function cannot take place, however, without the previous degen- 
eration of the entire peripheral end, and it is attended by a total 
loss of conductivity and irritability. At the end of about four 
days after division the continuous myeline sheath breaks up into 
a number of segments, and this division is accompanied by, or 
causes, a breaking of the axis. By the seventh day a very active 
proliferation of the nuclei of the nerve-sheath or neurilemma has 
begun. It is probable that this takes place by indirect division. 
After division the nuclei migrate, and several nuclei are often 
found in one internodal space. From the seventh to the four- 
teenth day absorption of the myeline takes place, together with 
the contained fragments of the axis-cylinder, until finally the 
remnants of these two substances entirely disappear. 

Protoplasm now begins to accumulate around the new nuclei, 
and increases until a continuous band or fibre of protoplasm, in 
which nuclei are imbedded, is formed within the old sheath. 
These bands constitute the ''embryonic fibres" of Neumann. 
After the formation of this new fibre a new sheath is made by 




Fig. 53. — Changes seen in the Repair of a Nerve after Division: I, absorption of myelin 
and multiplication of nuclei of nerve-sheath near points of absorption ; 2, embryonic 
fibre six and a half months after section ; 3, formation of myelin tube ; 4, newly-formed 
myelin tube (Howell and Huber). 



differentiation of the peripheral layers of this protoplasmic band, 
and it is supposed that the old sheath becomes part of the endo- 
neural connective tissue (Fig. 53). 



240 SURGICAL PATHOLOGY AND THERAPEUTICS. 

It is probable that these embryonic fibres have some of the 
properties of mature nerve-fibres, and that they can conduct 
impulses after having united with the normal fibres of the cen- 
tral end. Possibly this may be an explanation of the rapid 
return of sensation in some of the reported surgical cases. 

In case the ends of the divided nerves are not reunited, the 
degenerative changes proceed in much the same way as when the 
suture has been made; but the regeneration, beginning with the 
formation of the embryonic fibres, proceeds more slowly than in 
the case of suture, and never gets beyond the embryonic stage. If 
the reunion with the central end has been made, the regenerative 
changes go on to the formation of complete nerve-fibres having 
myelin sheaths and axis-cylinders. It is supposed that the new 
myelin is formed either by a myelin degeneration of the super- 
fluous nuclei or from the substance of the protoplasm by a process 
of chemical differentiation. 

When the myelin sheath is first formed it encloses a core which 
does not take the staining by osmic acid. Neumann and others 
assume that the new axis-cylinder arises from this core, but Ran- 
vier believes that one or more axes grow out from the axis of each 
intact fibre of the central end. In the central end the myelin and 
axis-cylinders disintegrate, and are absorbed for a certain distance: 
an embryonic fibre is formed from the new protoplasm arising from 
the nuclei, and in this a myelin sheath is first formed into which 
an axis-cylinder penetrates as an outgrowth from the end of the 
old axis. 

It is supposed, by Howell and Huber that in the normal fibre 
the nutrition of each internode is directly controlled by the inter- 
nodal nucleus — that is, the nucleus which presides over the portion 
of the nerve included between the nodes of Ranvier — and that the 
metabolic activity of the nucleus in turn is influenced by trophic 
impulses received through the axis-cylinder from the nerve-cen- 
tres. When the flow of impulses is interrupted the metabolisms 
of the nucleus and its dependent structures, myelin and inter- 
nodal protoplasm, are altered, and the degenerative changes in the 
myelin and axis-cylinder take place. When the embryonic fibre 
re-establishes a communication with the central end, the proto- 
plasm and nuclei are again brought under the influences of the 
trophic impulses from the nerve-centres, and consequently there is 
a new formation of myelin. 

According to Ranvier, every nerve-fibre consists of links united 
together at the "points of contraction of Ranvier." Each link 



THE PROCESS OF REPAIR. 241 

possesses a nucleus and represents a cell. It is evident that the 
protoplasm and nuclei of these cells play a prominent part in the 
process of repair, acting as a sort of neuroblast. It is not surpris- 
ing that repair in the peripheral portion of the nerve should be 
effected after so extensive a degeneration, when it is remembered 
that changes of this kind are going on during the entire physiolog- 
ical life of the nerve almost as regularly, according to some authors, 
as the growth of epithelium (Recklinghausen). 

It is evident, from what has preceded, that the connective-tissue 
elements play no part in the repair of nerve-tissue. The perineur- 
ium and the endoneurium throw out new connective tissue about 
the ends of the fragments and form a sort of callus which holds the 
nerve together. It is the growth from this tissue, principally, that 
forms the so-called "neuromata" or bulbous terminations of the 
ends of nerves in a stump. These tumors are really fibromata, and 
it is due to the contraction of the cicatricial tissue they contain 
that nerves thus affected are so painful. 

In regard to the clinical symptoms following nerve-section it 
may here be said that, although paralysis following division of a 
motor or of a mixed nerve is immediate and complete, there are 
conditions, such as have already been referred to, which mask this 
symptom to a certain extent. Free anastomosis with an adjacent 
nerve will give to a certain cutaneous district a sensibility it would 
not otherwise possess. Another portion of the skin may receive 
nerve-supply from several nerves. 

There is, normally, free anastomosis between the median and the ulnar 
nerves on the palmar aspect of the hand. It should also be remembered that 
there are numerous anastomoses between the musculo-cutaneous and the 
median nerves. The back of the hand is supplied not only by the radial 
and ulnar nerves, but also by other nerves. The musculo-cutaneous nerve 
may supply sensation to the skin of the thumb and to the radial portion of 
the dorsum, the posterior cutaneous nerve may supply the middle portion of 
the same region, and the external interosseous nerve may supply the oppos- 
ing sides of the index and middle fingers. 

There are, therefore, two factors to deal with in estimating the 
difference in duration and extension of disturbances of sensibility: 
first, the irregularities of nerve-distribution in individual cases, 
and, second, the collateral nerve-supply by anastomosis. The 
prognosis of nerve-suture varies greatly according to circum- 
stances. If a nerve is immediately sutured after division and the 
wound heals aseptically, the conditions are most favorable for 
restoration of function. If there is a loss of a portion of the 
nerve, the prognosis is less favorable for union, and the time for 

1G 



242 SCRGICAL PATHOLOGY AXD THERAPEUTICS. 

repair is in such case much longer. The nearer the injury is to 
the origin of the nerve, the longer is the period required for repair 
to be completed. The restoration of function is, however, the more 
rapid the nearer the point of division is to the peripheral end of the 
nerve. Excess of inflammation tends to produce cicatricial tissue 
which may be dense and may interfere with the reunion of the 
ends of the nerve, and not infrequently it forms a bulbous termi- 
nation, chiefly to the proximal end. 

Old injuries are not so easily repaired as fresh injuries, as the 
distal portion of the nerve has undergone degenerative changes 
which still remain. The prognosis is not hopeless in cases in 
which the nerve has been divided months or even years before. 

The question of repair of the nerve-tissue of the brain is one 
about which great doubt exists. Krebs examined two cases of 
brain injury — one recent, the other of long standing. Whether new 
cells were developed from the gray matter or neuroglia does not 
appear to have been definitely determined. From experiments on 
animals he concluded that the nerve-cells proliferated. Obersteiner 
says: "A divided nerve-fibre in the central nervous system is ren- 
dered permanently useless ;' ' according to Schieffendecker, a regen- 
eration of nerve-fibre takes place in the cords of very young animals 
after division, but repair is never seen in adult animals nor in man. 

Nerze-suture. — There are two methods of applying nerve-suture, 
which are known as the direct and the indirect suture. The direct 
suture is applied through the nerve-tissue, but the indirect suture is 
\ s 5 ed through the perineurium only. The direct suture possesses the 
disadvantage of injuring the nerve-fibres that are to be relied upon 
for repair. It has, however, a firmer hold upon the nerve, and is 
therefore more reliable when there is any tension upon the suture. 
When the ends of the nerve can be brought together without ten- 
sion the indirect suture is preferable, as it admits of a more accu- 
rate adaptation of the ends to one another. 

Kolliker prefers the finest catgut, for, although silk and metal 
sutures do not prevent healing by first intention, it is not absolutely 
certain that so sensitive a tissue may not be irritated by a more per- 
manent suture. When there is too much tension an auxiliary 
suture may be applied to the proximal end passing transver-r 
to the long axis, including adjacent tissue and skin if neces- 
This auxiliary suture holds the retracted proximal end in position, 
so that coaptation sutures may be inserted. 

In primary suture the ends of the nerve should be refreshed if 
they have been bruised or torn. In secondary suture a fragment 



THE PROCESS OF REPAIR. 243 

should always be removed from each end before they are brought 
together, and the bulb on the proximal end, if present, should be 
excised, thus removing the cicatricial tissue that has formed. In 
primary sutures the ends of the nerve are usually easy to find, but 
in secondary suture it is sometimes impossible to find one of them. 
When there is a considerable interval between the ends of the nerve 
the difficulty in bringing them together may be overcome in various 
ways. The simplest method, and the one which is effectual if the 
distance does not exceed 4 cm., is nerve-stretching. The limb 
should first be placed in a position favoring the approximation 
of the ends, and the stretching may be done with, the fingers or by 
dressing-forceps protected by rubber tubing. Letievant and Beach 
have both suggested plastic operations, the former having practised 
the operation upon the ulnar nerve. One or both ends are split 
longitudinally for some distance above the stump, and the portion 
thus released is reflected and united to the opposite end. 

Nerve-grafting has been tested experimentally by several ob- 
servers, and has been successfully performed by Landerer and Vogt 
on the human subject. It has been found that the implanted frag- 
ment takes no active part in the process of repair, and that the 
nerve-fibres undergo degeneration. It serves merely as a medium 
through which the nerve-fibres grow. Vanlair proposes a method 
called "suture tubulaire," which consists in slipping the two frag- 
ments into a piece of decalcified bone. He found, however, that 
the fragments occasionally grew past one another without uniting. 
He therefore lacerated the distal end to allow the new nerve-fibres 
to penetrate it. Assaky substitutes for the decalcified tubes catgut 
loops. The catgut sutures applied in this way are supposed to 
serve as guides to the growing nerve-fibres. 

In very large defects or in case the proximal end cannot be 
found Letievant proposed that the distal end should be implanted 
upon the trunk of an adjoining nerve, the trunk being opened at 
the point at which the nerve is sutured. When two neighboring 
nerves are divided, it may happen that it is only possible to bring 
together the distal end of one nerve with the proximal end of the 
other. This operation is advised in order to maintain the integrity 
of at least one nerve-area. Lobker in one case shortened the bone 
in order to bring the ends of the nerve together and at the same 
time to suture the tendons. 

The following case is interesting in this connection : A boy entered the 
writer's ward at the hospital for an unreduced dislocation of the elbow-joint. 
Attempts at reduction failing, the joint was laid open and all bands were 



244 



SURGICAL PATHOLOGY AND THERAPEUTICS. 



divided. The joint surfaces were brought in apposition, but it was then 
found that the ulnar nerve had been cut during the operation, and the ends 
were so far removed when the bones were in place that they could not be 
approximated. The joint was accordingly excised, and the nerve was then 
easily sutured. The wound healed by first intention, and at the end of two 
months the function of the nerve was restored and there was good motion at 
the elbow-joint. 

Kolliker prefers, above all, the method of nerve-stretching. 
He places Assaky's catgut loops next in order of preference and 
before plastic operation, as this method follows more closely the 
physiological processes during repair. 

Healing of Bone. — The cicatrix of bone is usually bone; that is, 
the bony tissue has the power of reproducing itself after injury, 
and it is only in exceptional cases that this does not occur. 

■When a long bone is broken there is a great deal of injury 
to the surrounding parts. The Haversian canals are ruptured, 
and there is a considerable oozing of blood between the bony 
fragments and in the surrounding tissues. This oozing is usu- 
ally sufficient in amount to form a tumor of considerable size at 

the seat of injury immediately after the 
accident, and serves in many cases as a 
guide to the diagnosis of fracture (Fig. 
54). The soft parts are also lacerated 
to a considerable extent. It is rare 
that the rupture of the periosteum does 
not occur. The sharp end of one or of 
both fragments may be thrust through 
the periosteum, or it may be pulled up 
from the ends of the bone by the dis- 
placement which takes place at the mo- 
ment of injury. 

As the result of such an injury to the 
part traumatic inflammation occurs at 
the seat of the fracture, and in a few 
days the tissues in the immediate neigh- 
borhood, if examined, are found infil- 
trated with blood-clot and are matted 
together by the exudation which takes 
place. The anatomical relations of the 
soft parts surrounding the bone are, for 
the time being, lost, and the upper and 
lower fragments are imbedded in an indurated mass of tissue, which, 
extending some distance above and below the seat of the fracture, 




Fig. 54. — Experimental Fracture 
(dog) at the end of the first week, 
showing bloodclot and detached 
fragment of bone. 



THE PROCESS OF REPAIR. 



245 



is known as the callus. This callus does not have any well-defined 
outline, and involves not only the bone and periosteum, but also the 
connective tissue and some of the surrounding muscular tissue. In 
a few days after the injury this inflamed mass begins to take on much 
firmer consistency than is seen in traumatic inflammations else- 
where. If examined during the second or third week of the pro- 
cess of repair, the tumor is found to consist no longer of blood-clot 
which has been absorbed, but of a dense tissue which has formed 
abundantly in and beneath the periosteum, and which in places 
appears to have developed into 
cartilage (Fig. 55). A w T eek or two 
later this material is transformed 
into a porous tissue surrounding 
the two fragments and holding 
them firmly together. In the 
mean time changes have been 
going on in the medullary canal. 
As the blood-clot is absorbed it 
is found that the fatty tissue of 
the canal has disappeared near 
the seat of the fracture, and that 
it is replaced by granulation tis- 
sue. Presently it is obvious that 
this tissue in turn has given place 
to newly-formed spongy bone, 
known as the internal callus. 
An intermediate callus is also 
recognized by some authorities as 
existing at this time between the 
ends of the bone, but it is clearly 
a development of bone-tissue from one of the other sources first 
mentioned. 

During this period but little change takes place in the sharply- 
defined ends of the shaft. Gradually, however, the dense cortical 
bone becomes more porous, so that at the end of one or two months 
a mass of spongy bone occupies the seat of the fracture. The 
newly-formed bone preserves the contour of the callus, forming a 
spindle-shaped swelling extending for some distance above and 
below the injury. From this time on, the new bone, formed from 
the medulla and the periosteum, is gradually absorbed, while the 
bone of one fragment, now continuous with the other, resumes its 
former density and becomes cortical bone once more. With the 




Fig. 55. — Experimental Fracture (dog) 
after forty-six days : ossification of callus. 



246 SURGICAL PATHOLOGY AXD THERAPEUTICS. 

absorption of the provisional bone the medullary canal and the 
periosteum resume their former relations. When the fragments 
so overlap one another that the continuity of the medullary canal 
is broken a portion of the cortical bone of each fragment is event- 
ually absorbed, and in this way the medullary canal is re-estab- 
lished. The object of this temporary bone-formation, known as the 
provisional callus, is to hold the broken fragments firmly together 
while the slow process of cicatrization in bony tissue takes place. 

The histological changes which occur during the process of repair 
after a fracture may now be considered. Already as early as the 
second day there is found in the immediate neighborhood of the 
fracture an infiltration of the parts with leucocytes. This infil- 
tration involves the lacerated periosteum and the connective tissue 
and muscular fibres. The extravasation of blood and the inflam- 
matory exudation combine to obscure the normal anatomical struc- 
tures. At some distance from the immediate neighborhood of the 
fracture there is found at this time an unusual activity in the 
deeper layers of the periosteum and in the adjacent bone. An 
active cell-proliferation takes place, in consequence of which fusi- 
form cells and angular or stellate cells abound. This tissue is in 
intimate communication with the interior of the bone, and is, in 
fact, continuous with the medulla through the connective-tissue 
system of the Haversian canals. It has been called by Ranvier 
the "periosteal medulla/ ' 

In a few days there is found in this tissue a thick layer of new 
cells imbedded in a finely striated intercellular substance, the cells 
being surrounded by a halo somewhat like that seen in cartilage, 
and the tissue being unusually dense and firm in appearance. 
This is the so-called " osteoid substance." Nearer the ends of 
the bone, and near the centre of the inflammatory mass known as 
the callus, the intercellular substance has a more transparent hya- 
line appearance, and during the early period of repair this portion 
of the callus consists lar^elv of cartilaee. 

If the osteoid substance just referred to is examined at the 
moment when the transformation into bone is taking place — 
that is, during the second or third week — it will be found that 
portions of this tissue take the staining fluid more readily than 
other portions, so that it has a more or less mottled appearance. 
This appearance is due to the deposit of lime-salts, and presently 
it is found that trabecular of bone have formed, and that the cells 
which were there before have now become bone-cells (Fig. 56). 
These cells are therefore known as osteoblasts. The spaces found 



THE PROCESS OF REPAIR. 



24: 



between the bony plates are now seen to be in communication 
with the Haversian canals and to contain blood-vessels. These 
vessels, emerging from the canals in the cortical bone, run at 




Fig. 56. — Ossification of Osteoid Substance in Callus, three weeks (dog) : osteoid substance 
above, shaft of bone below. The dark trabecule are formed of newly- ossified bone; 
between them are the Haversian canals in process of development. 

right angles to those supplying the shaft of the bone, and the 
grain of the new bone is consequently at right angles with that 
of the old (Fig. 57). 

This new spongy bone is now seen forming some distance from 
the seat of fracture, and gradually growing thicker as the ends of 
the fragments are approached. As this grows out from each end 
of the bone, it invades the cartilaginous callus, and the two but- 
tresses of bone developing from the ends of each fragment 
approach each other, and finally come together and form a bony 
bridge which unites the broken ends. This newly-ossified callus 
consists of spongy bone with a coarse meshwork, containing what 



248 SURGICAL PATHOLOGY AND THERAPEUTICS. 

might be regarded as an anastomosing network of medullary tis- 
sue. If these spaces are examined with a high power of the 






m; •■• ;. i- • • 1: -.- v , <£ "■ ' ' 



■ ; %!'# 



& 




% 



^ 



Fig. 57. — Experimental Callus (dog), three weeks. 

microscope, it will be found that they contain a vascular granu- 

• lation tissue surrounded 

at the margin of the 
9 g cavity by a row of cells 
(Fig. 58). It is evident 
fe that these cells are ac- 
tively concerned in the 
formation of new bone, 
layer by layer, as the 
deposition of lime-salts 
can be seen at certain 
points taking place be- 
tween the cells. In this 
way the spongy bone be- 
comes denser and more 
like cortical bone. The 
hyaline cartilage in the 
specimens examined by 

Fig. 58.— Detail Study of Three Weeks' Callus, show- tne writer seems to be 
ing osteoblasts forming new bone. absorbed as the bony 






A 



%**% 






&v 



"*m 



'U: 



,><» 



THE PROCESS OE REPAIR. 249 

growth shoots out from each end of the callus. The hyaline car- 
tilage may, however, at certain points form bone by the calcification 
of the intercellular substance and a change of the cartilage-cells into 
bone-cells (Bruns). Meanwhile, in the medullary canal, near the 
ends of the bone, the granulation tissue becomes changed into red 
or embryonic marrow; osteoid substance is formed around the mar- 
row adjacent to the cortical layer of bone, and new spongy bone 
is thus thrown out from the sides of the medullary canal until it 
is filled with a porous bony tissue. Hyaline cartilage is occasion- 
ally seen here, but this is the exception. 

During all these changes the ends of the cortical bone appear 
to remain unaltered. The Haversian canals are filled, however, 
with a round-cell infiltration, and the vascular spaces are grad- 
ually enlarged by an absorption of the lime-salts, probably by the 
production of some chemical substance developed by the granula- 
tion-cells. The ends of the dense bone become porous, and con- 
sequently there takes place a transformation of the bone in the 
immediate vicinity of the fracture and the surrounding callus 
into a mass of spongy bone. In this way the ends of the frac- 
tured bone become firmly united to each other. This process 
occupies many weeks, and in some bones it may be months before 
the dense bony tissue undergoes the changes necessary to hold the 
two fragments permanently together. When union has been accom- 
plished the callus undergoes absorption, which first occurs in the 
internal callus. In the medullary spaces, which again are becom- 
ing enlarged, there are found numerous giant-cells or osteoclasts 
that appear to play a prominent role in the process of absorption. 
The giant-cells usually lie in little excavations of the bone-sub- 
stance. In this way the outer callus also is gradually absorbed, 
but those portions of bone that are to remain permanently become 
denser, and finally assume the appearance of normal cortical bone. 

The amount of the callus varies greatly in different cases. It 
corresponds pretty closely with the amount of displacement of the 
fragments and with the severity of the inflammation. In ordinary 
cases of simple fracture the callus is found only in the angles 
formed by the broken ends of the bone. In animals that are 
allowed to run about during the process of repair the two ends of 
the bone are imbedded in a luxuriant callus which involves a con- 
siderable portion of the shaft. 

Sometimes there appears to be an inability on the part of the 
bone-producing structures to form new bone. The inflammatory 
tissue is absorbed and no new bone is thrown out, and as a result 



250 SURGICAL PATHOLOGY AND THERAPEUTICS. 

of this there is what is called an "ununited" fracture. If the 
ends of the two fragments are examined, it will be found that they 
have lost their sharp edges by absorption of bone, and that they 
are now more or less pointed. The two ends of the bone are 
united by a ligamentous band. In some cases nature attempts to 
form a new joint, and it is then found that the ends are held 
together by a capsule which when open is seen to contain a 
small amount of clear serum, and the ends of the bone are covered 
with a more or less perfectly formed hyaline cartilage. This con- 
dition is known as psend-arthrosis. In other cases the whole bone 
is absorbed, but this is extremely rare. The Warren Museum con- 
tains the arm of a grocer, whom the writer remembers to have seen, 
whose humerus was entirely absorbed after fracture. The causes that 
combine to produce non-union in bone do not appear to be under- 
stood thoroughly. The period of life at which an ununited fracture 
is commonest is, according to Bruns, between thirty and forty years. 
The chances of union during old age appear to be much more favor- 
able than has generally been supposed. Individual peculiarity has 
probably as much to do with the development of pseudarthrosis as 
any other factor. Among the constitutional causes mentioned as 
favoring non-union are pregnancy, syphilis, scurvy, and diabetes. 
It is probable, however, that pregnancy exercises but little influ- 
ence one way or another on the repair of bone. In syphilis it is in 
the later stages of the disease only that delayed union is observed. 

Local causes may materially contribute to the chances of non- 
union. Compound fractures supply twice as many cases of non- 
union as simple fracture. The displacement of the fragments and 
the presence of anatomical structures between the ends of the bone, 
such as muscle, tendon, nerve, or portions of the articular capsule, 
are conditions that seriously interfere with union. Imperfect fixa- 
tion of the fragments is also a fertile source of failure of the bones 
to unite. The femur and humerus, being single, are for this reason 
more likely to be the seat of ununited fracture than bones which 
are steadied by the presence of another bone. Unskilful treatment 
is not so frequent a cause of non-union as is supposed, but it is 
more likely to be followed by deformity at the seat of fracture. 

Healing of Arteries. — When the trunk of a large artery is 
wounded an abundant hemorrhage occurs from the cut in the 
vessel-wall into the surrounding tissues. If there is no open 
wound in the integuments, a large and tense haematoma is 
formed. The blood coagulates not only outside the vessel, but 
also in the wound in its wall and in the interior for a greater or 



THE PROCESS OF REPAIR. 



251 



lesser distance. Bleeding is thus arrested and the 
process of repair soon begins. As the clot is gradu- 
ally absorbed there is formed granulation tissue, 
which seals up the line of incision in the wall of 
the artery. The clot serves as a temporary pro- 
tection against hemorrhage, but it is soon absorbed, 
and the cicatrix which has meanwhile formed is 
composed of connective tissue only, and when sub- 
jected to arterial pressure is distended until an 
aneurismal sac is formed. 

When a ligature is placed around a large artery 
in continuity, the blood-current is permanently 
arrested, and it is possible for a durable cicatrix 
to be developed capable of resisting any strain 
that blood-pressure can bring to bear upon it. 
When the knot is firmly tied the intima and a 
variable portion of the media are ruptured, and the 
adventitia is gathered into a dense tendinous 
sheath around the constricted ends. 

The earliest change noticed is the formation 
of thrombi, the distal thrombus usually being 
smaller than the proximal. The size of the 
thrombi varies greatly. In aseptic operations 
they are exceedingly small, but they were pres- 
ent in all cases examined by the writer; in fact, 
a thrombus w T as seen in the ductus arteriosus 
of the new T -born infant, where local sepsis was 
highly improbable. 

During the first two days granulation tissue 
forms about the point of ligature and for some 
distance above and below. This tissue also 
varies with the amount of traumatism; it is, 
however, sufficient in all cases to bury the knot. 
If there is much trauma or if the wound becomes 
septic, the amount of this surrounding inflamma- 
tory tissue is increased and a callus of consider- 
able size is formed, which protects the vessels 
from the dangers of hemorrhage (Fig. 59). 

If repair progresses favorably, presently the 
adventitia is seen invaded by leucocytes in the 
neighborhood of the ligature, and the infiltration 
far to penetrate the thrombi. The solvent action 




« 




Fig. 59. — Carotid Ar- 
tery of Horse two 
weeks after ligature. 
A callus surrounds 
the ends of the ves- 
sel, between which 
the knot may be 
seen. The process 
of repair in the ar- 
terial wall has not 
yet begun (specimen 
1048, Warren Mu- 
seum). 

goes sufficiently 
of this granula- 



252 



SURGICAL PATHOLOGY AND THERAPEUTICS. 



tion tissue gradually disintegrates the bundles of fibres surrounded 
by the ligature, and the two ends of the vessels separate from one 
another, leaving the knot imbedded in the centre of the callus. 
The ends of the vessels, once released from the ligature, begin 
to expand, and the granulation tissue penetrates freely into the 
thrombi. Conditions are now reached closely resembling the 
repair in fractures which have just been studied. There is at 
this stage both an external and an internal callus. With the 
development of the granulation tissue new 
blood-vessels are formed, which spring from 
the vessels surrounding the ligature: these 
grow into the thrombi with the granulation 
tissue, and the thrombi are then said to have 
become ' ' organized.' ' The granulations that 
develop in this way form irregular masses of 
new tissue with spaces between them, which, 
when the superjacent clot is absorbed, be- 
come blood-spaces communicating with the 
lumen of the vessel. These spaces in their 
turn communicate with the new capillaries in 
the granulation tissue. This completes the 
first stage of the healing process. In arteries 
of considerable size this stage is completed 
by the fourth or fifth week (Fig. 60). 

The provisional structures are now grad- 
ually absorbed, and as they disappear it is 
found that the walls of the artery have not 
been inactive. A growth has taken place in 
the intima at an early stage of the process, 
and many of the wandering cells found in 
the clot come from this layer. As the clot 
and the internal callus disappear there is 
found a permanent cicatrix, which closes the 
ends of the vessel. This cicatrix varies in 
shape according to the presence or the ab- 
sence of large arterial branches. When no 
branch is present it has the shape of a cres- 
cent, the horns of which project symmetric- 
ally along the inner walls of the vessel. If the branch is given 
off on the side, the horn on that side is short, reaching only to 
the point of junction, while the horn on the other side projects 
much farther into the vessel, thus so narrowing its lumen as to 




Fig. 6o.-^Carotid Artery of 
the Horse two months after 
ligature. The ends of the 
vessel have opened and 
the provisional tissue has 
grown into the thrombus. 
Between the ends is the 
ligature sinus (Specimen 
1 048- 1, Warren Museum). 



THE PROCESS OF REPAIR. 



253 



allow it to taper gradually toward the mouth of the collateral 
branch. 

The cicatrix, when fully developed, consists of three layers. 
The inner layer is composed of endothelium formed in the way 
already described; below this is a layer of muscular cells, devel- 
oped by a proliferation of the cells of the media, and outside of all 
is a connective-tissue cicatrix, evidently formed by the outer walls 
of the vessel. There is, then, in the permanent cicatrix a reproduc- 
tion of the three walls of the vessel. When the cicatrix has fully 
formed the provisional tissue is absorbed, and in its place is found 
a cord uniting the two ends of the vessel. The mass of new ves- 
sels formed in the cal- 
lus has also disappeared. 
A small central vessel is 
usually seen penetrat- 
ing the cicatrix from 
the lumen and anas- 
tomosing with a sys- 
tem of capillaries sur- 
rounding the end of the 
arterial stump (Fig. 
61). In large cica- 
trices, w 7 hich sometimes 
extend a considerable 
distance into the ves- 
sel, this central arte- 
riole may be branched 
or tortuous, and may 
give to the cicatricial 
tissue a "cavernous" 
appearance. 

The formation of a 
muscular cicatrix is 
generally denied, but 
the writer, having made 
extensive researches 
upon this point, is con- 
vinced that a muscular 
cicatrix is developed. 
The reason why it has 
not been found is easily explained. The process of permanent cica- 
trization is so slow that investigators have examined specimens at 




Fig. 61. — Femoral Artery of Man three months after liga- 
ture, proximal end, termination of healing process. The 
cicatrix, composed partly of muscular cells, is penetrated 
by a small vessel. Below is the fibrous tissue which 
unites the proximal to the distal end. 



254 SURGICAL PATHOLOGY AND THERAPEUTICS. 

too early a period. The process requires a period of time varying 
from two to six months, or even longer, for its completion, accord- 
ing to the size of the vessel. Unstriped muscular cells proliferate 
much more frequently than is usually supposed. A physiological 
example of this is seen in the uterus, and every wound that unites 
involves a reproduction of these cells whenever new arterioles are 
formed. 

Some writers, as Senn, and Ballance and Edwards, advise the 
application of two ligatures to arteries of the largest calibre when 
tied in continuity. They must be drawn tight enough to approx- 
imate the walls without rupturing them. The object of this 
manoeuvre is to diminish the danger of secondary hemorrhage. 
When the ligature is applied in this way the ends of the vessels do 
not separate at once, but the vessel remains as an obliterated cord. 
It is probable, however, that the granulation tissue works its wav 
into the interior of the vessel in the manner already described. 
This process is clearly shown in the illustrations given by Ballance 
and Edwards in their admirable work. There is, therefore, no 
essential difference in the process of repair under these circum- 
stances. The walls of the vessel at the point of ligature are 
absorbed more slowly, however, and traces of them probably 
remain here and there in the cord uniting the two ends of the 
vessel. 

The old idea that the thrombus was organized is now so gener- 
ally abandoned that it is unnecessary here to discuss the question. 
The role of the thrombus is protective. In aseptic cases it is 
reduced to a minimum. In septic cases the whole length of a long 
trunk may be plugged by a clot. 

After the ligature of an artery in an amputation-stump the 
process of repair goes on in the manner described, but there are 
certain important modifications in it to adapt the circulation of the 
blood to the new conditions. The main artery of the stump so 
contracts that its calibre is greatly diminished. The cicatricial 
tissue which forms extends a long distance into the interior of the 
vessel, sometimes even throughout its whole extent. In this way 
its size is further diminished, so as to adapt it to the greatly 
diminished blood-supply needed for the part. The collateral 
branches increase in size, so that finally, instead of a large vessel 
ending abruptly as a cul-de-sac at the end of an amputation stump, 
there is a much smaller vessel which terminates in a large number 
of branches distributed in various directions. This diminution in 
the lumen of the main trunk is analogous to the change which 



THE PROCESS OF REPAIR. 255 

occurs in the hypogastric arteries after birth. There is a so-called 
''compensatory endarteritis," which in the new-born infant in- 
volves even the aorta. The changes seen after ligature in conti- 
nuity are analogous to those which follow obliteration of the ductus 
arteriosus. In both a substantial muscular cicatrix is secured at the 
point of obstruction to the blood-flow. 

In closing, a word about the ligature. Scarcely any subject in 
surgery has caused more discussion. Ligatures, usually of silk, 
were at first left with one long end, so that they could be with- 
drawn when they had cut their way through the vessel. This 
method was disadvantageous, as the ligature kept the wound open. 
Acupressure and torsion were substituted, but they were soon sup- 
planted by animal ligatures, which are absorbed. Since it has 
been understood that silk ligatures can be made aseptic, they are 
now used by most surgeons, as animal ligatures may become 
absorbed too soon, and a feeling justly exists that they are not to 
be relied upon. The proposition to apply two ligatures in such a 
way as to approximate the walls of a vessel without rupturing them 
is not likely to come into general favor. This method has not the 
merit of simplicity, and by it the dangers of suppuration are 
increased. If a ligature is not firmly applied, the lumen of the 
vessel may not be occluded. It is true that there is danger that the 
first half of the knot may loosen while the second half is being tied, 
and this accident has occasionally occurred, but its danger may be 
obviated by extra care in the application of the ligature. The old 
idea that the inner coats must be ruptured should no longer 
influence the surgeon. He should simply endeavor to place the 
ligature firmly enough upon the vessel to occlude it. A rough 
hempen or a braided-silk ligature may be needed to hold the first 
half of the knot in the largest arteries. In all other vessels the 
slipping of the knot need not be taken into account. Secondary 
hemorrhage after the ligature of arteries in continuity has become 
an accident of extreme rarity since the introduction of aseptic 
surgery. 



X. GANGRENE. 

Nkcrosis is the term usually employed by pathologists to denote 
death of a circumscribed portion of tissue. This term is com- 
prehensive in its significance and is applicable to all forms of local 
death. It is, however, usually limited to death of portions of 
internal organs where, owing to the absence of bacteria, putrefac- 
tion does not take place and the dead mass is absorbed, new tissue 
growing in from the surrounding parts to form a cicatrix. Gan- 
grene is a term applied to death of a part on the surface of the body, 
which part is readily accessible to bacteria, and therefore almost 
invariably is accompanied by decomposition. Mortification and 
sphacelus are terms also used to denote this variety of gangrene. 
Surgical custom has limited the use of the term "necrosis" to 
death of bone: it will be necessary, however, to employ the term 
in speaking of the death of portions of internal organs. 

The causes that produce death of a part are usually divided into 
three groups: the first group includes those causes which act 
directly upon the tissues by mechanical or chemical action, as 
when a part is crushed by violence or when a powerful escharotic 
is applied to the surface of the body; in the second group are 
those forms of gangrene caused by thermic agencies (exposure to a 
temperature of 54°-68° C. will produce death of a part, and cold, 
— 16° C, will also bring about a similar result); in the third group 
are those forms caused by a deprivation of the nutrition of the 
part, as when the blood-supply is cut ofT by the obstruction of a 
blood-vessel. Gangrene may be caused by the action of bacteria, 
either through the specific chemical substances which they liberate, 
or as the result of vascular obstruction due to the inflammatory 
process to which they give rise. 

A neuropathic form of gangrene has been described by several 
authors, who assume that the injury of the so-called "trophic 
nerves" is the cause of death of the part. The readiness with 
which decubitus, or bed-sore, appears after injury to the spinal cord 
is strongly suggestive of such a theory. Samuel calls attention to 
the fact that in spinal and cerebral affections the presence of skin 
rubbing against skin may be sufficient to produce gangrene, as on 
the labia and the scrotum, and that large doses of chloral adminis- 

256 



GANGRENE. 257 

tered to the insane cause profound sleep, during which in one night 
decubitus may be produced. It is, however, probable that the com- 
plete immobility of the paralyzed part and the simultaneous altera- 
tions in the innervation of the nutritive blood-vessels are sufficient 
to account for the changes produced, without assuming the pres- 
ence of a special set of trophic nerves. Gangrene may, however, 
be caused by the action of the vaso-motor nerves, as will be seen 
later. The condition of the nutrition of the tissues is also an 
important factor in the development of gangrene. In old and 
feeble individuals, in whom the circulation is impaired by weak 
heart-action or as the result of fever of a low type, gangrene fol- 
lows readily upon slight injuries. Individuals affected with dia- 
betes or with scurvy are peculiarly liable to gangrenous processes. 
The so-called " marasmic thrombi " are due usually to a slowing of 
the current and a coincident defect in the walls of the blood-ves- 
sels, thus favoring the coagulation of the blood. 

One of the first changes noticeable in the tissues after death of 
the part is the disappearance of the nuclei of the cells. In some 
cases chromatin (or the substances which take the staining most 
readily) collects in the form of granules, and is removed from the 
nucleus into the protoplasm of the cell, where it is dissolved and 
disappears. In other cases the nucleus itself loses its power of 
taking the staining fluid, is dissolved, and disappears. Such changes 
are readily seen in the epithelium of the kidney after embolism of 
a vessel: at the same time the affected tissue has a pale, cloudy, 
yellowish-white appearance, readily discernible by the naked eye. 

If the necrosed tissue contains substances capable of coagulation 
as well as the ferment necessary for coagulation, and if there are 
no processes, such as suppuration, unfavorable to this change, there 
may arise the condition described by Weigert as coagulation- 
necrosis. This condition is not unlike that which occurs when 
blood coagulates and a thrombus is formed. The cells of the tis- 
sue become altered to granular or hyaline masses and lose their 
nuclei. The intercellular substance also undergoes a hvaline 
degeneration. A striking example of this change is seen in mus- 
cular fibre when necrosis occurs as the result of trauma or of toxic 
infection or a burn. The connective-tissue fibres swell up and run 
together as a homogeneous mass. The dead tissues have a gray- 
ish-white color, or they may be tinged a dirty brown by the 
admixture of blood; a greenish-gray color indicates the beginning 
of decomposition. 

Recklinghausen has observed the formation of hyaline thrombi 
17 



2 5 8 



SURGICAL PATHOLOGY AND THERAPEUTICS. 



in the arterioles, and occasionally in the capillary vessels of gan- 
grenous parts. The hyaline masses appear homogeneous and, 
rarely, slightly striated, and fill only partially the lumen of the 
vessel. They appear to be formed during the contraction of the 
arteries, and to be connected in some way with changes in the 
arterial wall. In some cases the walls themselves of the capil- 
laries undergo a hyaline degeneration. These conditions have 
been observed in senile gangrene following burns, and in gangrene 
produced artificially in a cock's comb by the administration of 
spurred rye. 

Gangrene is in many cases so intimately connected with changes 
in the arterial system that it is necessary to refer briefly to some of 
the forms of arterial disease that are liable to produce it. The inflam- 
mation of the walls of arteries is almost invariably accompanied by the 
formation of new tissue — a condition which has an important bearing 
upon the circulation through the diseased channels. In the aorta 
an inflammation of the intima is accompanied by the production 
of warty, sometimes pediculated, growths which project into the 
lumen of the vessel. In the small arteries this growth from the 
intima involves a vessel through a considerable portion of its 
length, and it may be so extensive as to fill out the greater part of 
the lumen, producing a condition known as obliterating endarteri- 
tis (Fig. 62). This new formation is developed chiefly from the en- 
dothelium. Later, when 
the new tissue has de- 
veloped to a considerable 
extent, new vessels form 
in it which spring from 
the vasa vasorum. Many 
of them also communi- 
cate directly with the 
lumen of the vessel. It 
is by means of these ves- 
sels, some of which are 
of considerable size, that 
the circulation is main- 
tained. They are not 
mere blood-channels, but 
are supplied with a wall 
of their own. In cases 

Fig. 62.— Tibial Artery from a case of Senile Gangrene where SUCH extensive 

of the Foot (obiiterative endarteritis). changes have taken place 




GANGRENE. 259 

it will be found that also both the middle and the outer coats of 
the artery are involved in the inflammatory process. 

In many cases the inflammation terminates in atheromatous 
degeneration of the walls of the artery. In this case the begin- 
ning of the process is characterized by the formation on the inner 
wall of soft gelatinous nodules, which later become of almost car- 
tilaginous hardness, the result of a growth from the intima. Later 
the media and the adventitia become involved, and there is next dis- 
covered that degenerative or atheromatous changes are beginning, 
and when the nodules are laid open with the knife they are found 
to contain whitish and yellowish masses even in their deepest por- 
tions. As these masses soften the surface of the nodules becomes 
involved and an atheromatous ulcer is formed. If, however, the 
focus of degeneration is more deeply seated in the wall of the 
vessel, a cavity is developed containing fatty granules, cholesterin 
crystals, and fragments of tissue, forming the so-called ' ' athero- 
matous abscess" (Orth). These little abscesses may eventually 
break and discharge their contents into the interior of the vessel. 
Such crateriform ulcers offer an opportunity for the development 
of a thrombus. In the heart or the aorta such a clot would furnish 
the point of departure for an embolus. In the smaller vessels 
these formations lead to the obliteration of the lumen. These 
abscesses may heal and leave scars. In some of the atheromatous 
foci calcification may take place. These calcareous masses may be 
present in large numbers in the aorta covered by epithelium, or 
they may be found projecting from atheromatous ulcers. Their size 
and shape indicate that they have developed from the calcification 
of thrombi which have been deposited on the wall of the vessel. 
When all these various changes are present in different stages of 
development there exists the condition to which the name u end- 
arteritis deformans" has appropriately been given. 

The pathological changes produced in the wall of the artery by 
syphilis, and even by tubercle, are also sufficient to impair their 
function of nutrition. The effect of the changes in the arterial 
circulation must of course be great. Occurring as they do chiefly 
in advanced life, they are accompanied by great enfeeblement of 
the circulation at the extremities. If the arterial disease has been 
in the smaller vessels, the diminution of the force of the circula- 
tion is gradual, and absolute cessation is finally brought about 
either by the formation of a small thrombus or by some slight 
injury. The arterial supply being cut off, no fluid is brought to 
the dead part, and the veins, being unobstructed, have not retained 



260 SURGICAL PATHOLOGY AXD THERAPEUTICS. 

any venous blood in the part, consequently the part becomes grad- 
ually dried by evaporation and the form known as lk dry n or senile 
gangrene is produced. The coloring matter of the retained blood, 
being diffused through the dead tissues, imparts to them the cha- 
racteristic dark color of this form of gangrene. The dried tissues 
eventually become hardened to a leather-like consistency; hence 
the term mummification. 

When there is sudden arrest of the arterial circulation or death 
of the part through venous obstruction, there exists the condition 
known as moist gangrene. Bacterial infection soon brings about 
decomposition, during which gases are often developed, producing 
emphysema of the tissues. The blood-corpuscles are soon broken 
up and dissolved, and the cells become cloudy, lose their nuclei, 
and break down. The striations of muscular fibre disappear, and 
the mucin of the nerve-fibres runs into drops. Fat-cells become 
disorganized, and drops of fat are mingled with the swollen and 
softened fibres of connective tissue. In this way the tissues grad- 
ually become dissolved. 

While these changes are going on, the surrounding healthy 
tissue undergoes a reactive inflammation, due to the putrefactive 
changes which are developing in the gangrenous part. A red line 
of inflammation is formed at the point where the gangrene has 
ceased to spread, and the dark, discolored dead masses stand out in 
strong contrast to the bright-red color of the inflamed tissues about 
them. In this way the so-called u line of demarcation n is formed. 
When suppuration takes place the dead tissue becomes separated 
from the living, and the gangrenous tissue is in this way event- 
ually liberated. 

In necrosis of internal organs, of which infarction of the kid- 
neys or of the lungs is an example, there is rarely bacterial infec- 
tion, and suppuration does not take place. There is, of course, no 
line of demarcation in such cases, but the living tissues grow into 
and replace the dead substance, which is gradually absorbed. 

Senile gangrene occurs most frequently in people over fifty 
years of age, and is caused, as before stated, by arterial disease. 
Death of the part may take place from a thrombosis of the small 
vessels or in the arteries leading to it, or it may be due to an embo- 
lus. The immediate cause of gangrene is often a weakening of the 
heart's action in an individual in whom, owing to the conditions 
mentioned, the peripheral circulation is already very feeble. A 
slight injury, like the bruising of the foot or even a "hang-nail," 
may be the starting-point of the disease. 



GANGRENE. 261 

The part most frequently attacked is the foot, one or several of 
the toes being affected, it being extremely rare to find the disease 
in the upper extremities. The earliest symptom is redness and 
swelling of one of the toes, accompanied sometimes with consid- 
erable pain. This condition is very apt to be mistaken for an 
attack of gout. The characteristic discoloration, however, appears 
and settles the diagnosis. It usually involves the whole toe, but 
does not spread beyond. A line of demarcation forms at the meta- 
tarso-phalangeal articulation, and the toe shrinks or it becomes 
coal-black in color, and the integuments become dry and wrinkled, 
and sometimes almost as hard as wood. The pain has by this time 
ceased, and the patient's general condition may not be materially 
affected. In favorable cases the toe is gradually separated and falls 
off, and the wound heals by granulation. In many cases, however, 
the attempt of nature to form a line of demarcation fails and the 
gangrene spreads to one or more adjacent toes. The surrounding 
tissues are now in a state of inflammation, as there is more or less 
decomposition in the gangrenous part, owing to the presence of 
bacteria, and their bright-red color is in strong contrast to the 
blackened toes. If the gangrene does not spread, a line of demar- 
cation forms along the border of the dead part, but the disturbing 
influences of septic inflammation are in many cases sufficient to con- 
tinue the process. Many of the bacteria form substances having an 
escharotic action upon the adjacent tissue, and the nutrition of the 
neighboring parts must be in good order to enable the tissue to re- 
sist them. When gangrene has once reached as far as the dorsum of 
the foot, the prognosis becomes very grave, and the patient, after 
nature has made several vain attempts to form a line of demarca- 
tion, dies of exhaustion at the end of a prolonged illness. In such 
cases as this it usually will be found at the autopsy that the tibial 
arteries have been involved in an obliterating inflammation or that 
their walls are rigid and atheromatous. There is, therefore, the 
danger that the gangrene may also involve the leg as far as the 
knee, and this is occasionally the case where an extensive throm- 
bus has formed throughout the length of these vessels, extending 
even into the popliteal and femoral arteries. 

Haidenhain, in a careful examination of a number of legs 
amputated for senile gangrene, found evidences of thrombosis 
either of the femoral artery or of its branches. In 11 out of 20 
cases there was almost complete obliteration of the larger vessels 
by old thrombi, many of which had already become organized. 
According to this writer, thrombi form at the point of bifurcation 



262 SURGICAL PATHOLOGY AND THERAPEUTICS. 

of the popliteal and fill the tibials in their whole length. Such 
thrombi were found quite often in diabetic cases. 

Gangrene of the foot and leg combined is, however, more often 
due to embolism than thrombus. Here the onset is more acute, and 
generally occurs in an individual who has had signs of previously 
existing heart or arterial disease. The first symptom may be a sharp 
pain in the foot and the calf of the leg, and when seen early the af- 
fected portion of the limb is blanched and cold and pulsation in the 
tibial artery is absent. Such a group of symptoms in an individual 
with a history of cardiac disease places the diagnosis beyond a doubt. 
The most frequent point of lodgment of such an embolus is the 
bifurcation of the popliteal artery. A thrombus forms immediately 
upon the proximal side of the embolus, and the femoral artery may 
be obliterated for a considerable portion of its length. The follow- 
ing cases of embolism of the popliteal artery will serve to illustrate 
the clinical features of this affection: 

In one case, a hospital patient, the leg was removed jnst below the knee- 
joint, and the patient made a good recovery. In another case embolism 
occurred in a patient affected with heart disease after a very exhausting polit- 
ical campaign. The limb when first seen was cold and pulseless ; the patient 
had suffered a great deal of pain for twenty-four hours. The pulse was rapid 
and intermittent and the general condition of the patient was bad. Ampu- 
tation was performed on the third day, after an attempt had been made to 
improve the patient's strength. By this time the limb had become discolored 
for some distance above the ankle, but the muscles and the skin of the calf 
still retained a natural color. Amputation was performed at the lower third 
of the thigh, and the vessels were found plugged with thrombi, so that there 
was no hemorrhage. A large fresh thrombus projected from the femoral 
artery, and it seemed to extend into the vessel for a long distance. Slight 
sloughing of the flaps and connective tissue of the interior of the wound 
occurred a few days later, but the sloughs eventually separated and were 
replaced by healtlry granulations. A week after the operation a sharp pain 
occurred in the chest, with a rise of temperature, followed by the expectora- 
tion of a dark clot, indicating the development of an infarction of the lung. 
The patient died three months later of an infarction of the spleen, which sup- 
purated, a large abscess being found in this region at the autopS3\ 

Embolism of the brachial artery may also occur, but not so 
frequently as in the femoral artery and its branches. 

Treatment. — In the mildest cases of senile gangrene, when one 
toe only is involved, it is advisable to refrain from interference. 
The metatarso-phalangeal articulation lies deep, and meddlesome 
surgery may cause the gangrenous process to extend. In the 
student days of the writer this old surgical rule existed — namely, 
that in spontaneous, or idiopathic, gangrene, as it is often called, 



GANGRENE. 263 

the surgeon should wait for the line of demarcation, but that in 
traumatic gangrene he should amputate at once. 

The mortality following conservative treatment in senile gan- 
grene was, however, so large that the old rule has been abandoned, 
and it is now advised by the best authority to interfere as soon as 
it is evident that there is not sufficient power to form a line of 
demarcation. A good rule to follow is to advise amputation as 
soon as the gangrene has invaded the sole or the dorsum of the 
foot, for it is then liable to spread with much greater rapidity. 
The point at which amputation should be performed is a ques- 
tion about which authorities differ. As has been seen, the tibial 
arteries are usually diseased in their entire length, and the circu- 
lation in them is therefore almost always more or less diminished. 
For this reason many surgeons prefer to amputate above or below 
the knee-joint; that is, at a point well removed from the region 
of the disease. In one case the writer operated with good results, 
on a feeble individual who had diabetes, at the middle of the leg, 
but if the strength of the patient will bear it, it is better to ampu- 
tate at the lower third of the thigh. 

Before undertaking to interfere surgically it is well to ascertain 
the probability of similar processes occurring in other portions of 
the body, as the following case will show: 

A man fifty years of age, but in appearance much older, entered the 
hospital with gangrene of the great toe and a portion of the same foot. He 
had injured it two months before in very cold weather. The leg was ampu- 
tated a few days later at the point of election . The patient recovered from 
the operation and the wound healed well during two weeks, but he died on 
the seventeenth day after three days of severe illness. At the autopsy there 
were found, in addition to an obliterating endarteritis of the tibial arteries 
with calcification, obliteration of the splenic artery, thrombosis of the 
splenic vein, and anaemic necrosis of the liver and spleen. The immediate 
cause of death was thrombosis of the femoral vein and pulmonary artery. 

The amount of disease in this case was such as to make it 
doubtful whether an amputation should have been attempted 
with much hope of success. In case a conservative treatment 
is decided upon, careful attention should be given to the patient's 
general condition. Cardiac tonics and a nourishing diet with 
stimulants are indicated. The parts should be kept in as anti- 
septic a condition as possible, and every opportunity should be 
given to the gangrenous toes to become mummified. In case of 
embolism an effort should be made to save the limb. The parts 
should be elevated slightly to favor venous circulation, and be 
encased in warm cotton, care being taken to avoid all constriction 



264 SURGICAL PATHOLOGY AND THERAPEUTICS. 

of the circulation by the dressings. When once the diagnosis 
and the extent of the gangrene are established, the sooner ampu- 
tation is performed the better. 

A condition very closely allied to senile gangrene is that known 
as diabetic gangrene (PI. III.), which occurs also in elderly indi- 
viduals. It is important, therefore, that the condition of the 
urine should be carefully determined in all cases of senile gan- 
grene. The picture of the disease so closely resembles that 
already given that there is little to add to it. Furuncle and 
carbuncle, bed-sores, pneumonia, abscess, and gangrene of the 
lungs also occur in diabetic patients. Diabetic individuals bear 
surgical operations so poorly that in general it is the custom to 
advise against operations in persons affected with this condition 
of the system. The writer would not, however, hesitate to advise 
amputation in a case of spreading gangrene. 

A gentleman sixty years of age applied to the writer for treatment of 
gangrene of the third toe of the left foot. The right leg had been ampu- 
tated two years previously for gangrene. There was found well-marked 
diabetes, and when the gangrene began to spread to the foot amputation 
was performed in the middle third of the leg with a successful result. There 
was marked atheroma of both tibial arteries. By careful attention to diet 
the patient recovered his strength, and when seen by the writer a year or 
two later appeared to be in excellent health. 

Haidenhain in a recent article undertakes to show that gan- 
grene in diabetes is due to arterio-sclerosis of the vessels, as in 
senile gangrene, and advises amputation at the thigh as soon as 
the gangrene has invaded the sole or the dorsum of the foot. Of 
13 cases of amputation below 'the knee, including disarticula- 
tion of toes, Chopart's and Lisfranc's amputations, and amputa- 
tion of the leg, only 2 recovered; 2 cases died from gangrene of 
the flaps, and later, in 9 cases, amputation was made at or above 
the knee. Of 27 primary and secondary operations above the 
knee, 19 cases were cured and 8 died of diabetic coma. In none 
of these cases did the condition of the wound appear to be the 
cause of death. Haidenhain advises the cutting of very shallow 
flaps. 

It is customary to describe moist gangrene as a separate variety, 
but many cases of senile gangrene may be moist, this condition 
depending in such cases on the rapidity with which the disease 
has established itself and on the amount of tissue involved. A 
frequent cause of moist gangrene is injury to the large vessels by 
gunshot wounds or the complications which result from fractures. 



PLATE III 





sue M 



Diabetic Gangrene. 



PLATE IV 





2*~ 






Gangrene of Leg, following ligature of femoral artery for popliteal aneurism. 



GANGRENE. 265 

Traumatic gangrene is almost always of the moist variety. Gan- 
grene of this type may occur also from acute inflammation and 
from burns and frost-bite. Obstruction to the venous circula- 
tion from thrombosis or from pressure by bandages or dressing 
will retain the fluids of the body in the part and prevent any 
tendency to mummification. As examples of venous obstruction 
there may be cited strangulated hernia and severe forms of para- 
phimosis. The sloughing of flaps after an amputation for injury 
is also an example of moist gangrene. 

The characteristic appearances of the traumatic form of moist 
gangrene are best seen after an injury to some large vessel, such as 
the popliteal or the brachial artery (PI. IV.). For the first twenty- 
four hours it is doubtful whether the limb will live or not. Pul- 
sation of the tibial (if the lower extremity is the injured member) 
is wanting from the beginning. The limb is blanched and is 
colder than the opposite limb. The patient, who has suffered 
from the pain of the original lesion, is relieved of pain with the 
approaching death of the limb; and, inasmuch as he is still able 
to move his toes, he fails to appreciate the grave nature of his 
injury. 

The skin discoloration which begins at the end of twenty-four 
hours is usually a symptom that may be relied upon as character- 
istic, but extensive ecchymosis may sometimes give a misleading 
impression. The writer well remembers a case of frost-bite where 
the greater portion of both feet were of a coal-black hue: he 
obtained the patient's consent to a double amputation above the 
ankle, but at the moment of the administration of ether doubts 
as to the propriety of operating determined him to wait another 
day. The patient eventually escaped with the loss of one or two 
toes of each foot. 

The irregular distribution of color shows that the circulation 
has been greatly impeded, and livid spots alternating with an 
unusual pallor are more certain indications of approaching gan- 
grene. When decomposition sets in a greenish tinge is added to 
the variegated coloring of the limb. The part now becomes 
swollen and of a soft, unnatural, pulpy consistency. Pressure 
fails to bring about a paleness of the skin with a subsequent 
return of color. Blisters filled with a bloody serum form upon 
the surface. The swelling and discoloration are partly due to 
increased blood-pressure in some of the vessels of the part, for 
there is still a limited circulation in the veins even when mortifi- 
cation has set in. At this period there is an entire loss of sensation 



266 SURGICAL PATHOLOGY AND THERAPEUTICS. 

in the part, and the patient will bear the prick of the scalpel with- 
out flinching. In many cases it is only by some such demonstration 
as this that he is convinced that there is no longer need of an 
attempt to save the leg. In favorable cases the gangrene is con- 
fined to the injured part, and in this case a line of demarcation 
forms, but even before this line shows itself it becomes evident 
from the contrast between the white healthy skin and the swollen 
and discolored tissues that the gangrene will not spread. The color 
deepens in hue, and becomes eventually either dark green or coal 
black. The tendency of the deeper parts to soften is very marked, 
and muscular tissue soon becomes reduced to the consistence of a 
brick-dust paste. Tougher tissues, like tendons, retain their form 
much longer, and bone is rarely altered by the gangrenous process. 
When the putrefactive changes are more acute, the chemical 
changes are probably brought about by more malignant forms of 
bacteria, as the streptococcus or malignant oedema bacillus. The 
saprogenic organisms also play a prominent role. In such cases 
the gangrene readily spreads, and it is accompanied by the forma- 
tion of gases which spread through the loose tissue in advance of 
the disease. These gases consist of ammonia, sulphide of ammo- 
nium, sulphuretted hydrogen, and volatile fatty acids. In the foul, 
discolored, and greasy fluids that ooze from the wound there are 
found leucin, tyrosin and fat-crystals, crystals of triple phosphate, 
and clumps of dark pigment. The gangrene rapidly spreads, and 
while the patient is endeavoring to make up his mind to the loss of 
a foot the whole limb may be destroyed. The changes of color in 
the skin are rapid and striking in their effects. The part is dark 
green or black, the leg a livid bronze color, and streaks of green 
and bronze run in long narrow bands up the thigh. The constitu- 
tional disturbance is profound. The patient suffers from acute sep- 
ticaemia; there are collapse with a small and frequent pulse, rapid 
respiration, profuse perspiration, and choleraic discharges from the 
bowels. The citation here of a few cases will serve to indicate the 
grave nature of the affection: 

A man was shot through the leg by a discharge from a fowling-piece, the 
posterior tibial artery being lacerated in its lower third. Pulsation could not 
be felt in the artery at the ankle-joint. An attempt was made to save the 
limb. On the third day the foot became gangrenous, and the disease spread 
so rapidly that twenty-four hours later amputation at the junction of the 
middle and upper third of the thigh failed to save his life. The whole limb 
was in a state of acute putrefaction, being distended with gas and emitting a 
foul odor. The skin presented a variegated coloring of green, brown, bronze, 
and black. 



GANGRENE, 267 

An elderly woman addicted to the use of alcohol fell and sustained a com- 
pound Colles' fracture, the sharp edge of the shaft of the radius piercing the 
radial artery. When seen a few days later the arm was swollen above the 
elbow and was greatly discolored ; the hand was closed, claw-like, and greatly 
swollen. A foul discharge oozed from the wound. Amputation was performed 
at the middle of the arm. The softer tissues of the gangrenous portion were 
almost completely macerated. The patient made a good recovery. 

A boy fifteen years of age sustained a fracture of the bones of the forearm 
while trying to vault over a bale of goods. The patient was brought into the 
hospital a few days later with the forearm in splints and in a gangrenous con- 
dition. The next day the arm was much swollen and discolored, and of a deep 
bronze hue. Emphysema could be felt over the shoulder and the correspond- 
ing half of the chest. There being no wound through which decomposing 
fluids and gases could escape, a number of free incisions were made in the 
parts already dead to relieve the tension and favor drainage. In this way the 
spread of the gangrene was arrested, and the next day a line of demarcation 
formed below the shoulder-joint, and the boy eventually recovered. 

These cases of traumatic gangrene require the most prompt 
interference on the part of the surgeon. They are known as 
u fulminating gangrene" or "gangrenous emphysema," or, in the 
expressive French language, as gangrene foudroy 'ante. 

Gangrene may result from some of the forms of inflammation 
with intense congestion of the parts. In some cases of hyperaemia 
accompanying inflammation there is, as has already been seen, a 
slowing of the blood in the capillaries, and in this condition red 
corpuscles are often forced through the walls of the vessels, giving 
rise to the hemorrhagic type. This degree of congestion precedes 
total stasis, which, when it occurs on a large enough scale, produces 
death of the part. But death is still more frequently caused by the 
direct poisonous action of bacteria. When an inflammation is about 
to terminate in gangrene, the bright red color becomes a deep livid 
red, mottled with blue, later a purple hue, and finally black. The 
underlying tissues are boggy and are distended with gas and decom- 
posed fluids. There is great swelling of the adjacent lymphatic 
glands. At the seat of the lesion the muscles and tendons are mace- 
rated, the bone is denuded and surrounded by a putrid fluid min- 
gled with pus. It is in this fluid that one finds the largest number 
of micro-organisms. The constitutional disturbance is profound. 
There is great physical prostration and the signs of septicaemia are 
well marked. A post-mortem examination shows that the viscera 
are congested and cedematous, and present hemorrhagic infarctions 
(Park). 

Such gangrenous types of inflammation occur only from some 
of the most poisonous forms of bacterial infection, as, for example, 



268 SURGICAL PATHOLOGY AND THERAPEUTICS. 

the bacillus of malignant oedema. Occasionally a man is brought 
into the hospital with an entire arm in this condition, the result of 
an acute phlegmonous inflammation arising from a poisoned wound 
in the hand. The infection occurs often after the most trivial lesions, 
as the prick of some dirty tool or instrument. 

The treatment of moist gangrene varies greatly according to the con- 
ditions under which it develops. The old rule, to amputate at once 
in traumatic gangrene, has but few exceptions. If there is no tend- 
ency to spread, a time can be chosen for the operation when the 
condition of the patient is satisfactory to the surgeon. In spread- 
ing gangrene the loss even of hours is sometimes fatal to life. 
There are but few cases in surgery that are more urgent than these. 
Free incisions may sometimes relieve tension and permit the escape 
of foul gases and fluids, but such a resort is not to be depended 
upon to arrest the process, and it should only be employed when 
amputation is not permissible on account of the low state of the 
patient. The process, once fully developed, may leave the patient 
in such a state that life can only be saved by amputation. 

It is hardly necessary here to remind the reader that good food 
and stimulants, both alcoholic and cardiac, may be needed to 
develop all the strength which the system can command. Alco- 
holic stimulation is about the only form of treatment that can be 
depended upon in this grave condition. 

Gangrene from frost-bite may result partly from the effects of 
cold and partly from the enfeebled condition of the patient. A 
temperature of — 16° C. is sufficiently low to produce this condition. 
Exposure to cold in a drunken sleep is the commonest way in 
which this form of gangrene is acquired. The parts — usually the 
feet — at first are blanched, and later become purple or marbled, 
running in shade from a deep black in the toes to a mottled purple 
which may extend above the ankles. 

The effect of cold upon the small arteries is to cause them to 
contract to prevent the flow of blood. If this condition of spasm 
is maintained too long, the arteries will not dilate and the blood 
will never return. If kept up for a certain length of time, they 
will dilate to such an extent that the part will become engorged 
with blood, and gangrene may be produced in the same way as in 
the acute congestion described above. There will be an intense 
passive hypersemia with stasis in the vessels, that may lead to 
death of the part or to a chronic inflammatory process. The blood 
must therefore be allowed to come back gradually, and it is for this 
reason that treatment by cold is so often used. The Esquimaux 



C. INGRENE. 



269 



place a frozen man in a room at the temperature of zero Fahren- 
heit, and gradually raise the temperature to the desired point. The 
practice of bringing a case of frozen feet into the warm ward of a 
hospital should, if possible, be avoided. The part, at all events, 
should be kept in an atmosphere cooled by ice-bags while the 
skin is kept dry. Usually the threatening color will gradually 
disappear, or will prove to be due chiefly to extravasated blood 
beneath the epidermis, and the gangrene will be found quite lim- 
ited in extent. 

The use of poultices to warm the dead parts should be avoided r 
as they promote suppuration and favor burrowing of pus. After 
the warmth has fully been restored an antiseptic dressing should be 





IfefeK 



X. 



Fig. 63. — Gangrene of the Toes from Frost-bite. 

applied until the line of demarcation is established, when the dead 
parts can be removed by an operation if necessary (Fig. 63). 

A not uncommon cause of gangrene is extravasation of urine. 



270 SURGICAL PATHOLOGY AND THERAPEUTICS. 

The effect of an ammoniacal urine laden with bacteria is to cause 
an extensive slough of the connective tissue and occasionally of 
the scrotum. Free and early incisions are indicated in such cases. 
When a portion of the scrotum becomes gangrenous and separates, 
the remainder retracts, and the loss of integument appears to be 
much greater than it really is. Although the testicles and cords 
may be exposed in their entire length, they will eventually be 
covered in by the granulating wound. The treatment of such cases 
consists in free incisions through the whole extent of the extrava- 
sated area. An incision on the median line, dividing the scrotum 
into halves as far down as the point of rupture in the urethra, is 
usually called for. 

A rare occurrence, which the writer has seen only once, is gan- 
grene of the urethra and glans penis due to obstruction of its 
nutrient artery. In this case the gangrenous parts were carefully 
dissected away and a clean external wound was left, but the patient 
succumbed to a gangrenous cystitis. 

Noma, or cancmm oris, is the result of gangrenous stomatitis 
affecting the cheek. Noma occurs most frequently as a compli- 
cation of one of the eruptive diseases of children, such as scarlet 
fever; it may also affect the pudenda. It is evidently produced 
by a septic inflammation, although Samuel regards it of neurotic 
origin, as it does not pass the middle line and is developed without 
preceding inflammatory symptoms. Schimmelbusch has examined 
one case for bacteria, and found small bacilli, often in pairs and 
sometimes in long filaments, growing along the boundary-line of 
the living tissue. These bacilli grow in gelatin without liquefying 
it at the temperature of the room, and injected into rabbits they 
cause abscesses. They did not stain by Gram's method. Lingard 
examined five cases and found a bacillus 4-8// long; when injected 
into rabbits it caused inflammation, and death on the tenth day. 

Foote examined one case of noma and found bacilli, but he 
failed to obtain cultures of them. Sections taken from the skin at 
the edge of the ulcer covering the malar bone, and stained by 
Gram's method, showed an outer zone of necrotic tissue and an 
inner zone of normal tissue. At the edge of the necrotic zone 
bacilli were found packed closely together to the exclusion of all 
other bacteria along the line of necrosis : this gave the impression 
that they were eating directly into the sound tissue. They were, 
in fact, seen infiltrating the healthy connective tissues, though in 
much less abundance than along the line of necrosis. Thus far, 
there is not sufficient evidence to show that an organism which 



GANGRENE. 271 

may be regarded as specific has been obtained by a number of 
independent observers. 

The cheek is usually affected, and the loss of substance is so 
extensive that the whole side of the month is frequently exposed. 
The bones of the superior and inferior maxilla may be laid bare, 
and the teeth may frequently drop out. After the slough has sepa- 
rated the wound appears like a sharply-cut gigantic ulcer, involv- 
ing the side of the nose and the entire cheek. After cicatrization 
takes place a large opening still remains, and the case requires an 
elaborate plastic operation for its relief. At the pudenda the dis- 
ease usually begins at the labial margin and extends to the clitoris, 
the nymphae, and the hymen, and sometimes to the urethra. The 
disease may spread to the perineum, to the anus, or to the thigh 
(Hamilton), and, as in the mouth, the sloughing is deep and fre- 
quently extends quite to the bone. 

The constitutional treatment in noma is of the greatest import- 
ance, and it is chiefly through this treatment that life may be 
saved. Quinine and iron may be given in full doses, and stimu- 
lants also. Disinfecting gargles may be used for the mouth and 
antiseptic dressings for the pudenda. A few drops of an emulsion 
of sty rone 3ss, glycerin £iv, water giij, added to a glass of water, 
forms an agreeable and efficient disinfectant for the mouth. In the 
use of antiseptics care should be taken to avoid poisoning by the 
absorption of the drugs used. 

Ergotism, or gangrene produced by eating grain containing ergot 
of rye {Secale comutum), was a disease of the seventeenth and 
eighteenth centuries, and at one time produced great havoc among 
the farmers in France, Switzerland, and other countries of Europe. 
It has been denied that the drug could produce this effect when 
used experimentally upon animals; but according to Recklinghau- 
sen the characteristic effect was produced in a cock's comb, where 
a spasm of the arterioles was observed after its administration, and 
the contractions were severe in degree and of long duration. At 
one time the mortality of ergotism is said to have been very great, 
entire hands and even whole limbs being affected by the gangren- 
ous process. 

Decubitus, or bed-sore, is a form of gangrene produced by pres- 
sure. When the slough separates it leaves a large ulcer, which 
has already been described. Many believe decubitus to be an 
example of neuropathic gangrene, as it occurs so readily after 
injuries to the spine. The rapidity with which sloughs form on 
the heels after such injuries is certainly suggestive of trophic 



272 SURGICAL PATHOLOGY AND THERAPEUTICS. 

changes. There is no direct proof of this theory, however, and 
the general opinion appears to be that the gangrene is due to 
enfeebled circulation with uninterrupted pressure. Continued 
pressure, even when too light to cause pain, as from a tightly- 
applied tourniquet or from splints, produces the same effect. Bed- 
sores form readily in patients affected with low forms of fever, and 
they are in such cases partly due to enfeebled heart- action. 

In the treatment of decubitus great care should be taken to 
prevent pressure on the parts liable to be affected, such as the 
heels and the sacrum. The skin should be kept clean and dry, 
and one of the chief advantages of a trained nurse in such cases 
is the care given to the condition of the integuments of the back. 
Daily friction with alcohol, keeping the parts dry with toilet-pow- 
der, and the use of ring pads to remove pressure are the principal 
means of prevention. Since the days of trained nurses bed-sores 
have greatly diminished in number, and their development is a 
source of much less anxiety to the attending physician. The same 
cannot be said, unfortunately, of the use of hot-water bottles. It 
has been the writer's lot to see, as the result of their careless use, 
extensive sloughs form upon patients while still under the influ- 
ence of ether. It is a good rule not to allow any hot-water bot- 
tles in the bed of a patient coming out of ether: the bed can be 
heated sufficiently before he is placed in it. 

A rare form of gangrene, but one which is nevertheless occa- 
sionally seen at the present time, is that known as symmetrical 
gangrene or Raynaud's disease. It is a variety of dry gangrene 
characterized by two prominent features — the absence of any ana- 
tomical lesions of the blood-vessels, and the symmetrical develop- 
ment of the disease in the two halves of the body. It may be 
found in both an upper and a lower extremity, or in all four 
extremities, and occasionally the ear, the cheeks, and the nose 
are affected. Mills reports a case in which the tip of the tongue 
was slightly affected. A somewhat similar condition is that pop- 
ularly known as " dead finger," which comes on after exposure ta 
cold, and which is not unfrequently seen in young ladies after a 
cold bath. The affected finger is distinctly paler than the others 
and is cold; the circulation, however, soon returns. In the con- 
dition associated with symmetrical gangrene the disturbance of 
the circulation is more profound, and there occurs what the 
French call "local asphyxia." The pallor is succeeded by a 
cyanotic color of varying degrees of intensity. On pressure the 
color disappears, and returns very slowly, showing great feeble- 



GANGRENE. 273 

ness in the circulation. When in this condition the ends of 
the fingers, the parts most frequently affected, are often quite 
painful. The color later becomes almost black, and minute 
blisters appear on the tips of the fingers. The blisters become 
filled with a sero-purulent fluid, break, and leave excoriations 
which may remain several days. The color now begins to return, 
the excoriations heal, and a little conical tubercle is left just be- 
neath the edge of the nail. The improvement is, however, only 
temporary; the same changes recur, and may be repeated during a 
period lasting one or two years. In an advanced stage the ends of 
the fingers are covered with a number of little white scars, the 
skin being indurated, and they have a thin, sharp, withered look, 
as if they had been pinched in a vise and had preserved the shape 
thus given to them. When the vascular disturbance reaches that 
point which is sufficient to cause death of the part, the transparent 
cyanotic pulp of the finger has at its central part a small black 
mass of tissue which subsequently separates as a slough. 

No cardiac disease is found in cases of symmetrical gangrene, 
and the general condition of the patient gives evidence of no form 
of organic disease anywhere. The vaso-motor disturbance remains 
at its height for about ten days, and convalescence is established 
at the end of from three weeks to several months. Occasionally,, 
after one or two attacks, the condition becomes more or less perma- 
nent, and the part affected is continually cold and torpid. At times 
the skin of the backs of the hands and the fingers becomes thick- 
ened and rigid, and the fingers are held semiflexed and ankylosed. 

The two affections most likely to be mistaken for this disease 
are chilblains and senile gangrene. In chilblains all the extrem- 
ities are not likely to be found affected, and the disease is limited 
to certain periods of the year. Senile gangrene is rarely bilateral: 
it is much more extensive, and the characteristic condition of the 
arteries is usually present. Owing to the predominance of pain it 
has sometimes been mistaken for gout. The prognosis of sym- 
metrical gangrene is favorable. If the stage of gangrene develops 
itself at the end of a week or ten days, it is probable that a com- 
plete recovery will follow the separation of the eschars. If, how- 
ever, the disease does not reach this point, but comes and goes, 
there is danger that it will settle down into a chronic condition. 
In four-fifths of the cases the disease is found in women. In the 
great majority of cases it occurs between the ages of eighteen and 
thirty years. As a low temperature is an exciting cause, the dis- 
ease is more frequently found on the approach of the winter 

18 



274 SURGICAL PATHOLOGY AND THERAPEUTICS. 

months. Not infrequently there may be premonitory symptoms 
for one or two winters, with return to health in the summer 
season, and a final termination in gangrene. 

The following case is the only example of this affection which 
the writer has seen: 

A rather feeble woman, twenty-five years of age and a native of Scot- 
land, presented herself at the hospital in June, 1878. She had been in good 
health until four months previously, at which time she suffered frequently 
from nose-bleed. Soon after this she noticed that the tips of the fingers and 
toes became red. At the time of entrance to the hospital the pulps of the 
fingers and toes were discolored. The borders of the affected area resembled 
the semi-transparent purple of a grape. There was none of the reddish tint 
seen in strangulated intestine. The lightest shades were also essentially 
purple in tint: near the centre the hue deepened until it was difficult to 
determine whether or not the tissues were gangrenous. The patient did 
not complain of much pain, but was totally incapacitated for work, owing 
to the condition of her hands. On two of the finger-tips were patches of 
gangrene. In a few daj-s several sloughs separated from the fingers as dry, 
black eschars, the largest being about the size of a ten-cent piece. The 
treatment consisted in administration of iron internally and good food, and 
the application of resin cerate to the parts, About two months later, when 
the patient left the hospital, the fingers had healed and presented a red and 
shrivelled look. There was no gangrene of the toes. 

Symmetrical gangrene, according to Raynaud, is a form of 
ischaemia due to contraction of the arterioles, which contraction 
may sometimes extend back as far as arteries of considerable size 
(radial pulse). In the lighter forms of spasm there occurs ' ! local 
syncope " or " dead finger. ' ' The veins probably are also con- 
tracted. When the reaction following the spasm is incomplete 
there is " local asphyxia." The veins having the smallest amount 
of muscular fibres relax first, and the venous blood flows back into 
the capillaries, but stops here, as the arteries are still contracted. 
As a result of this condition there is a certain amount of stagnation 
in the larger veins, and sometimes slight oedema. The arterial con- 
traction was demonstrated in the retina in a case where there was 
disturbance of vision during the attacks. It is evident, therefore, 
that the disturbance lies in the vaso-motor apparatus. The sym- 
metrical character of the lesion is explained by an irritation of one 
of the vaso-motor centres of the cord which brings about a spasm 
of the vaso-constrictors. 

As the disease is situated in various parts of the body, the 
centre of irritation is not always at the same point, and as there 
exist several vaso-motor centres, different points may become the 
seat of the contractions. The vaso-motor nerves are affected not 



GANGRENE. 275 

only by direct irritation, but may also be susceptible to reflex action. 
An example of the latter is the contraction of the vessels of one 
hand when the other hand is suddenly plunged into very cold 
water. 

Inasmuch as symmetrical gangrene follows occasionally the 
puerperal state or may show itself periodically at the menstrual 
epoch, it is but reasonable to suppose that the reflex irritation 
may take its origin in the uterus. Some of the cases described 
by Mitchell as erythromelalgia have a resemblance to this affec- 
tion, and some of them undoubtedly appear to be symmetrical 
congestions. Although this arterial spasm shows itself at the 
most peripheral portions of the body, it probably is to be found 
elsewhere, but the parts being less exposed to the loss of heat, 
gangrene does not occur. 

The treatment of symmetrical gangrene consists principally in 
the administration of tonics and in placing the patient under the 
best hygienic conditions. Raynaud recommends the use of con- 
stant descending currents to the spine. The use of some local 
stimulating application may serve to restore the tone of the cir- 
culation of the part after the arterial constrictions have ceased. 
During the separation of the sloughs a careful antisepsis of the part 
should be maintained. 

The action of chemical agents as the cause of gangrene has been 
noted. There is one drug (now so universally used as an antisep- 
tic agent) which occasionally exerts such a powerful local action 
that it is desirable for the writer to warn against its use under cer- 
tain conditions. Watery solutions of carbolic acid when applied 
to the fingers on compresses have in a number of cases been fol- 
lowed by gangrene of the entire finger. Several such cases have 
come to the writer's knowledge. Strong solutions of this acid 
have a numbing influence upon the part, and, in the early days 
of its use, strong carbolic acid was experimented with as a local 
anaesthetic for minor operations. A prolonged application of a 
compress wet in a carbolic solution is followed by the evaporation 
of the water and a corresponding concentration of the agent. The 
surgeon should therefore avoid entirely the use of solutions of this 
drug on the extremities of the body. The danger of " carbolic ga?i- 
grene" is one that should always be kept in mind. 

Ainhum (a native word meaning to saw off) is an affection 
which occasionally terminates in gangrene, although spontaneous 
amputation of the part affected may occur without gangrene. It 
is a disease characterized by a constriction of the integument of 



276 SURGICAL PATHOLOGY AND THERAPEUTICS. 

the little toe at its plantar fold, producing a deep fissure which 
gradually encircles the toe until the latter is attached to the foot 
by a narrow pedicle. Ainhum, which occurs almost exclusively in 
negroes, is found in Africa and the West Indies ; it has also been 
met with among the Hindus. It is seen more frequently in men 
than in women. Cases are reported in which the finger was 
affected, but they are rare. It is said to be hereditary. 

There is apparently little if any ulceration during the constrict- 
ing process. Ainhum has been compared to scleroderma, and Eyles 
describes a thickening of the deeper layers of the cutis vera. Accord- 
ing to Duhring, it may be grouped with " degenerative fibromata. n 
The epidermis is much thickened. The bones undergo an osteo- 
porosis or a rarefying ostitis. The condition known as ' ' obliterat- 
ing endarteritis ' ' has been observed. As the constriction deepens 
the end of the toe enlarges, and appears as if it had been encircled 
by an elastic ligature. The disease may last from one to ten years. 

A healthy male negro, fifty-three years of age, suffering from this affection, 
presented himself at the Massachusetts General Hospital. His family resided 
in the British Provinces. His grandfather, father, brother, and two sisters had 
all lost the little toe of the left foot. The toes of all had been removed by a 
surgeon, except that of one sister, who pulled off her toe. 

In the case of the patient the disease began four years before in the same 
toe. There had been no pain, although sensation was felt in the affected part. 
The disease when first seen resembled a soft corn, in which a deep furrow 
existed. The furrow gradually increased until the toe was only attached by 
a pedicle about one-eighth of an inch in diameter. There was a slight exco- 
riation at one point, but no distinct ulceration, the toe being much enlarged. 
On removal the toe was placed in alcohol, and after hardening was divided 
by a horizontal incision, the knife easily cutting through the bone. The 
phalanx had almost entirely disappeared, and the bulk of the tissue appeared 
to be made up of a mass of adipose tissue. The cutis and epidermal layers 
did not appear to be hypertrophied. The patient made a good recovery. 

No cause has yet been assigned for this affection. It has been 
suggested that the constriction has intentionally been produced by 
a ligature. Possibly it may be due to mechanical friction, owing 
to some peculiarity in gait or in footgear. Sudan noticed in sev- 
eral cases that lumbar pains preceded the local affection, and he 
does not regard the disease as local in origin. It has been sug- 
gested that division of the constricting bands of fibres at an early 
stage of the disease might check its progress. In the majority of 
reported cases amputation was performed. This can be done usu- 
ally with a pair of scissors, as the bone has disappeared from the 
pedicle. 



XL SHOCK. 

"i\.LTHOUGH the fact of death ensuing upon injuries of parts 
not essential to life, even when unattended by hemorrhage, and 
upon operations not usually esteemed hazardous, has not escaped 
observation, writers and teachers seem to have contented them- 
selves with the bare statement of it, either from an impression 
that, being an equivalent in effect to death on the spot or being 
due to an idiosyncrasy moral or physical, the further consideration 
of the subject in a practical view was unavailing." Thus writes 
Travers, the senior surgeon of St. Thomas's Hospital, in 1826. 
Previous to this time the term "shock," as now used, had rarely 
been employed as a surgical expression. Guthrie, however, speaks 
of the "shock of the injury," and Sir Astley Cooper says in his 
lectures, "The most severe injuries by shock to the nervous sys- 
tem cause death without reaction." James Latta, in 1795, is said 
to have been the first to have used the word to describe this 
condition. 

This profound but somewhat obscure disturbance of the system, 
although probably recognized by the practical surgeon from time 
immemorial, has only received the somewhat tardy attention of 
medical writers, and even at the present time its pathology is but 
very imperfectly understood. At all events, the most diverse views 
have been held by those who have studied the condition of the sys- 
tem in shock. Its importance was first recognized by English 
writers, to whose efforts no doubt much of our present knowledge 
is due. Travers, Jordan, Savory, and many others have given the 
subject special study. It seems strange that the progressive Ger- 
mans should have allowed shock to have passed almost unnoticed 
until 1867, when Billroth and Neudorfer first called attention to it. 

The nomenclature of the affection is not a large one. The terms 
"traumatic torpor" and "stupor" have been used by Pirogoff; 
1 ' prostration without reaction ' ' is spoken of by Travers ; Savory 
uses "collapse" as the title to his article; and " neuroparalysis " 
has been employed by those who have attempted to explain the 
nature of shock in this way. In Germany Wundschreck and 
Erschiitterung are terms that have been used to a limited extent, 

277 



278 SURGICAL PATHOLOGY AND THERAPEUTICS. 

but they have given way, as in France, to the very expressive 
English phrase which is now almost universally employed. 

Though the literature of the subject is considerable since it 
received a place in surgery, yet few writers attempt to define the 
nature of shock. Its pathology is usually passed over briefly, and 
the term may be said to have been employed indiscriminately to 
describe all cases of sudden death following injury without hem- 
orrhage. In America and in England the condition has been 
regarded as a general depression of the nervous system without 
any very well-defined idea as to what the nature of the change was. 
Mansell-Moullin has defined it a little more accurately as a reflex 
paralysis or inhibition of the nervous system. In France, Blum 
explains shock as an arrest of the heart's action, due to reflex irri- 
tation of the pneumogastric nerve. In Germany many writers 
have adopted the theory of Fischer, who attributes the weakness of 
the heart's action and the other phenomena of shock to a reflex 
vaso-motor paralysis whereby the abdominal vessels are hyperae- 
mic, and the heart, brain, and other organs are correspondingly 
ischsemic. 

Before going more deeply into this question let there be a 
mutual understanding of the clinical picture which this subtile 
condition produces in the human organism, when, as Gross graphi- 
cally puts it, " the machinery of life has been rudely unhinged." 

A patient is brought into the hospital with a compound commi- 
nuted fracture or with a dislocation of the hip-joint added to other 
injuries, where the bleeding has been slight. As the litter is gently 
deposited on the floor he makes no effort to move or look about 
him. He lies staring at the surgeon with an expression of com- 
plete indifference as to his condition. There is no movement of 
the muscles of the face ; the eyes, which are deeply sunken in their 
sockets, have a weird, uncanny look. The features are pinched and 
the face shrunken. A cold, clammy sweat exudes from the pores 
of the skin, which has an appearance of profound anaemia. The 
lips are bloodless and the fingers and nails are blue. The pulse is 
almost imperceptible; a weak, thread-like stream may, however, be 
detected in the radial artery. The thermometer, placed in the rec- 
tum (it would be useless to attempt to take the temperature in the 
axilla), registers 96 or 97 ° F. The muscles are not paralyzed 
anywhere, but the patient seems disinclined to make any muscu- 
lar effort. Even respiratory movements seem for the time to be 
reduced to a minimum. Occasionally the patient may feebly throw 
about one of his limbs and give vent to a hoarse, weak groan. 



SHOCK. 279 

There is no insensibility (coma is not observed in cases of shock), 
but he is strangely apathetic, and seems to realize but imperfectly 
the full meaning of the questions put to him. It is of no use to 
attempt an operation until appropriate remedies have brought 
about a reaction. The pulse, however, does not respond; it grows 
feebler, and finally disappears, and "this momentary pause in the 
act of death " is soon followed by the grim reality. A post-mortem 
examination reveals no visible changes in the internal organs. 

The two principal theories as to the nature of shock are based 
on certain functional disturbances in the vascular and nervous sys- 
tems respectively. Fischer takes the ground that shock produces 
a paralyzing effect upon the heart in a manner similar to that pro- 
duced upon the frog in Goltz' s experiment, which consists in the 
infliction of repeated slight blows upon the abdomen (p. 85). 
When the heart begins to pulsate again it remains small and 
pale, and receives in the diastole very little blood, and is there- 
fore able to throw out only a small quantity into the system. This 
condition was ascribed by Goltz to a lack of tonicity in the vessels 
of the abdominal cavity, but later he w T as convinced that there was 
a very general vaso-motor paralysis. It was shown also that the 
same condition could be brought about by blows received in other 
parts of the body. This lack of tonicity Goltz subsequently showed 
was not confined to the arteries, but might affect the veins also, and 
in this way such large quantities of blood might be received in the 
vessels of the abdominal cavity, as has been shown experimentally 
to be the case after division of the splanchnic nerves, that the heart 
and large vessels elsewhere could receive but an extremely small 
quantity of blood. According to Fischer, then, the great mass of 
the blood stagnates in the abdominal veins and arteries during 
shock. This, he thinks, is a sufficient physiological explanation 
of the symptoms of shock. As the skin is anaemic, it is pale, 
cold, and without sensation. Experiment has shown that muscles 
deprived of their blood are rigid and unable to perform their func- 
tions, and the great muscular weakness is therefore accounted for. 
The irregularity and the temporary cessation of the heart's action 
account for the small, irregular, and absent pulse. The cerebral 
ansemia explains the mental phenomena of shock and the nausea 
and vomiting. 

Schneider also adopts the theory of a reflex paralysis of the 
vaso-motor nerves, as based upon the views of Falk and Sounen- 
burg on the cause of death after extensive burns. According to 
Schneider, every extreme irritation produced by surgical operations 



28o SURGICAL PATHOLOGY AND THERAPEUTICS. 

or by injuries causes at first contraction, and subsequently general 
dilatation, of the blood-vessels. ' ' The heart is unable to force the 
small amount of blood through the empty vessels. Its own mus- 
cles are insufficiently supplied with oxygen, and it gradually ceases 
to beat. The great lowering of the temperature of the body can 
be explained by the diminished blood-pressure, and consequently 
the increased difficulty in providing oxygen for the tissues, or by 
the retarded flow of blood and the consequent increase of the loss 
of heat, or finally by the direct influence upon the heat-centre. ' f 
Thus the theory of Fischer is extended so as to include a vaso- 
motor paralysis of the whole vascular system. This view is 
accepted by Mansell-Moullin, who considers it an enormous 
advance on all previous views, but still cannot accept it as thor- 
oughly sufficient to explain all the phenomena of shock. He 
assumes these vaso-motor changes to be produced by inhibition, 
rather than by simple reflex paralysis, and, arguing on this basis, 
suggests that the same power may be the direct and immediate 
agent influencing the nerves that govern sensation, motion, and 
volition as much as those that control the walls of the blood-ves- 
sels. The molecular action which constitutes nerve-force may be 
interfered with, perhaps even interrupted, not only in certain cen- 
tres that control the heart and vascular system, but also in other 
centres. " Shock is to be regarded as an extreme and general man- 
ifestation of that inhibition with the power of which, as regards a 
few organs, physiology has made us acquainted. ' ' "In short, ' ' he 
concludes, ' ' shock is an example of reflex paralysis in the strictest 
and narrowest sense of the term — a reflex inhibition, probably in 
the majority of cases general, affecting all the functions of the 
nervous system and not limited to the heart and vessels only." 

The vaso-motor theory is also held by Gross, for he states that 
shock is essentially dependent upon reflex paralysis of the entire 
circulatory system, but especially of the heart and abdominal ves- 
sels. It has gained numerous adherents in Germany, among whom 
may be mentioned Kulenburg and Schede. 

Grceningen, however, takes exception to the vaso-motor- paral- 
ysis theory, and shows that Goltz himself did not regard this as 
shock, but rather as syncope or ' c fainting. ' ' Many of the symp- 
toms of shock can, he acknowledges, be explained by this theory, 
particularly those belonging to the circulation — not those, however, 
connected with motion and sensation. The anaesthesia and paresis 
produced in the posterior extremities of a rabbit after ligature of 
the abdominal aorta do not correspond to those symptoms produced 



SHOCK. 281 

by shock. The return of blood to a part thus rendered anaemic is 
usually exceedingly painful, and there are also peculiar creeping 
sensations. No anaesthesia is produced by the Esmarch bandage. 
In shock there is no sensation whatever in the muscles. Anaemia 
of the brain is one of the symptoms of syncope, not of shock. If 
Fischer's theory were correct, the signs of shock and hemorrhage 
would be the same, but, as will be seen later, there are important 
differences in this respect. In rabbits subjected to the Goltz exper- 
iment Grceningen was unable to demonstrate an anaemia in the 
peripheral arteries and muscles. In rabbits dying from shock he 
found the abdominal arteries and veins empty. All possibility of 
hyperaemia of these vessels may be removed by administering Cal- 
abar bean to these animals, and yet the symptoms of shock may be 
produced. Many claim that in the mammalia sufficient blood can- 
not be made to collect in the abdominal vessels to produce this 
so-called "intravascular hemorrhage." Division of the splanchnic 
nerves in animals does not produce the symptoms of shock. Cases 
of sudden abdominal plethora following premature delivery, or of 
sudden emptying of effusion from the abdominal cavity, are incor- 
rectly called "shock," according to Grceningen, being in reality 
brain-anaemia. 

In addition to these arguments, there may be adduced the prac- 
tical experience of those surgeons who are accustomed to operations 
in the abdominal cavity. It has certainly been the writer's expe- 
rience that the symptoms of shock are not accompanied by any 
marked change in the blood-supply to the abdominal vessels. A 
careful analysis of this theory shows, therefore, conclusively, that 
it does not account satisfactorily for all the symptoms of shock. 

Many surgeons regard shock as a sort of heart failure, a tem- 
porary paresis of the muscles of the heart. Savory, whose arti- 
cle has long been an established authority on shock, says: "The 
heart is powerfully affected through the nervous system, and its 
action is arrested." Blum has endeavored to explain the func- 
tional disturbance of the heart in shock by the action of the 
pneumogastric nerve similar to that caused by experimental irri- 
tation of the nerve, which produces either a diminution in the num- 
ber of beats or a sudden interruption of the heart's movements. 
This explanation would not account for those cases of shock in 
which the rapidity of the heart's action is increased. Irritation 
of this nerve does not always produce the same changes in blood- 
pressure, whereas in shock there is always a general and considerable 
diminution in the blood-pressure. This theory, moreover, does not 



282 SURGICAL PATHOLOGY AND THERAPEUTICS. 

explain the weakness of muscular action and the diminished sensi- 
tiveness and many other symptoms of shock. In cases of irrita- 
tion of the pneumogastric nerve produced in man by pressure upon 
the carotid region the number of pulse-beats per minute is dimin- 
ished one-half, but the beats continue to be strong, as does also the 
action of the heart. The arterial pressure was temporarily dimin- 
ished, but afterward was above normal. 

Grceningen observed the case of a hussar who was kicked on 
the left side of the neck by a horse. In addition to a paralysis of 
the left vocal cord, there was, for several days, a remarkable reduc- 
tion of the heart-beats to thirty per minute. The pulse was, how- 
ever, strong and the heart's action good, although slightly irregu- 
lar. Meyer found that by electric stimulation the heart's action 
could be arrested for a minute in warm-blooded animals, but he 
was unable to produce any permanent impression upon the motor 
apparatus of the heart. Finally, post-mortem examinations show 
that irritation of the pneumogastric causes arrest of the heart in 
diastole. In cases of death from shock the heart is often found 
contracted and empty. It need hardly be added that paralysis of 
the heart produced by irritation of the pneumogastric nerve cannot 
be accepted as the cause of shock on such evidence. 

Many of those authors who have been inclined to accept the 
vaso-motor theory of shock have nevertheless not been fully satis- 
fied with its capacity to account for all the symptoms. Mansell- 
Moullin's opinion on this point has already been quoted. The 
same view is held by Mitchell, who says: " Either the shock of a 
wound causes paralysis of vaso-motor nerves and sequent conges- 
tion, with secondary alterations, or it destroys directly the vital 
powers of a centre. Now, there is no reason why if shock be com- 
petent to destroy vitality in vaso-motor centres or nerves, it should 
be incompetent to so affect the centres of motion and sensation." 

Cooper was clearly of the opinion that death in some injuries 
was caused by both direct and indirect shock to the nervous sys- 
tem. Billroth undertook to explain the change thus produced as 
a molecular disturbance of certain portions of the brain. Brown- 
Sequard recognizes an irritation of the cervical cord, the medulla, 
and the neighboring central structures as shown by the effect upon 
the vagus, the sympathetic, and sensitive nerves. There is, he 
thinks, a weakening also of the nerve-power at the respiratory 
centre. 

One of the most thorough and complete studies of the action of 
the nervous system in shock has been made by Grceningen. An 



SHOCK. 283 

indication of this action is given by Leyden, who ascribes the phe- 
nomena of shock to a powerful irritation either directly upon the 
cord or indirectly through a peripheral sensitive nerve, by which a 
profound molecular disturbance is produced in the nerve-tissue, 
which is thereby incapacitated from receiving less intense stimuli. 
The functions of the cord may thus be paralyzed or be reduced to 
a minimum. Among these functions there must be included not 
only sensation and motion, but also those which preside over the 
heart, the vaso-motor nerves, and the respiration. "The brain," 
he says, "does not participate, the mind is clear: it is rare that 
stupor, coma, or delirium is present." 

Let us see for a moment what the result is of the functional 
activity of the nerve when subjected to a mechanical irritation. If 
a sensitive nerve is irritated, a change takes place in its equilibrium 
which is transmitted peripherally and centripetally. As to the 
centrifugal change nothing is known. The centripetal irritation 
brings about a change which is called "sensation." In the nerve as 
well as in the nerve-centre there is a certain amount of consump- 
tion of tissue, perhaps also a molecular change. In fact, it is known 
that after repeated irritation there is a chemical change in the 
nerve, and that its power of responding to further irritation is 
diminished. The mere act of function, therefore, brings about a 
change which is called "fatigue," and, when extreme in degree, 
" exhaustion." The fatigue disappears after a certain interval with 
rest, and the nerve resumes its former power of responding to irri- 
tation. In the case of the motor nerve the irritation expresses itself 
centrifugally in muscular action. Here also both nerve and muscle 
may become exhausted by repeated irritation. 

As Savory puts it, "Action involves exhaustion, and repose is 
needed for repair. The greater the effort, therefore, the greater 
the exhaustion." The exhaustion of the peripheral nerve de- 
pends partly upon the degree of the irritation, and partly also upon 
the suddenness with which it is exerted. It follows, therefore, 
that a single sudden maximum irritation produces the highest 
degree of exhaustion. Experiment shows that the irritation is 
not confined to the nerve alone, but spreads from its point of 
origin to certain portions of the central nervous system. 

So far as the amount of the irritation goes, Grceningen recog- 
nizes four degrees: (1) The lowest is without perceptible action on 
the nerve; (2) the second disposes of the sense of feeling, such as 
touch, sight, hearing, taste, and smell; (3) a stronger irritation 
effaces more or less the acuteness of these perceptions, and brings 



284 SURGICAL PATHOLOGY AND THERAPEUTICS. 

out prominently the sensation of pain or of such disagreeable sen- 
sations as loathing, disgust, etc. ; and (4) the highest degree of 
irritation destroys all sensation either temporarily or permanently. 

Bach lower degree of irritation leads insensibly up to a higher 
one. The sensation of heat and cold may merge into that of pain. 
So with the other senses: a strong light may blind, an intensely 
loud noise may cause deafness. Again, a higher degree of irrita- 
tion prevents the perception of one of lower grade : the lips are 
bitten to suppress the pain of an operation. A maximum of 
irritation may be reached when all special senses are destroyed, 
and even pain itself is not felt. With all these changes of func- 
tion the nerve remains anatomically the same, to all appearance. 
The paralyzed nerve and the nerve afflicted with the most intense 
neuralgia may have no marks to distinguish one from the other. 
The disturbances recorded are therefore considered purely func- 
tional. 

Let us now look at the nerve-centres. The change in them 
produced by irritation is usually called "reflex inhibition," but 
the phenomena thus produced can as readily be explained by the 
theory of fatigue of these centres caused by over-irritation. Reflex 
paralysis is an example of fatigue of the nerve-centres. I^ewisson 
showed that if the kidney of an animal was seized and squeezed 
by the hand, a temporary paralysis occurred in the posterior 
extremities and reflex irritability was for the time destroyed. 
Mitchell reports numerous cases of reflex paralysis following 
injuries to nerves. Here exists paralysis of the motor apparatus 
as the result of irritation of a sensitive nerve. These paralyses 
were in remote regions and unconnected with the injured limb, and 
they appeared after the first shock of the injury had subsided. 
Langenbuch showed that after nerve-stretching the pulse was 
smaller and more frequent or slower, the breathing more super- 
ficial or changed in rapidity. 

From these examples it is seen that during the simple process 
of innervation the nerve-centres may become fatigued to a greater 
or lesser extent, and that when the irritation of the peripheral 
nerves is very intense the functions of those portions of the cord 
receiving or transmitting these impressions may be temporarily 
interrupted. A condition of fatigue or exhaustion is thus pro- 
duced that shows itself in a weakening or suspension of the sen- 
sitive and motor functions of these portions of the cord. 

The changes which are due to exhaustion must not be con- 
founded with inhibition. The reflex centres are a portion only 



SHOCK'. 285 

of those that are affected. The motor centres are also paralyzed, 
sensation is weakened, the perception of pain is benumbed, the 
temperature falls, respiration is less active, the vaso-motor centres 
are enfeebled, and the strength of the heart fails. As Grceningen 
says, the spinal cord up to its point of origin from the brain is sud- 
denly overwhelmed, as it were, and can only regain its vitality 
after a complete rest. 

It has hitherto been supposed that the nature of this condition 
of the cells of the cord was not demonstrable by any method of 
examination, and the change which takes place was therefore 
regarded as molecular, such as one might expect to find in a 
purely functional disturbance. The observations of Hodge, how- 
ever, are very suggestive in this connection. This observer has 
made a microscopical study of changes due to functional activity 
in nerve-cells, hoping to find alterations corresponding to those 
seen in the cells of a gland which is performing its functions. 
The gland-cell during rest becomes filled with granules, and dur- 
ing secretion these granules pass out, generally leaving the cell 
shrunken. " The necessity for rest in a gland-cell is made appar- 
ent by its loss of substance. If nerve-cells do not lose substance 
or change in some way, why are we tired at night?" To test this 
question Hodge subjected the spinal ganglia of frogs and cats to 
electric stimulation for several hours, comparing the changes 
observed in the cells with the normal cells and with stimulated 
cells after a period of rest. He also studied the effects of normal 
daily fatigue in sparrows, swallows, and bees. The ganglia of 
birds obtained in the early morning were compared with those 
of birds killed at the close of a hard day's work. He concludes 
that metabolic changes are as easy to demonstrate microscopically 
as similar processes in gland-cells. These alterations consist in a 
marked decrease in the size of the nucleus, and a change from a 
smooth and rounded to a jagged, irregular outline. There is a loss 
of the open reticulate appearance of the nucleus, and it takes a 
darker stain. There is a slight shrinkage in size with vacuolation 
in the cells of the spinal ganglia, and considerable shrinkage with 
enlargement of pericellular lymph-space for cells of the cerebrum 
and cerebellum. The protoplasm does not take the staining mate- 
rial so well as when in its normal condition. There is a decrease 
in the size of the nuclei of the cell-capsule when present (Fig. 64). 

These interesting results seem to throw new light upon the 
condition of the ganglia of the cord and medulla in the condition 
known as shock, and render the supposition highly probable that 



286 



SURGICAL PATHOLOGY AND THERAPEUTICS. 



in this profound functional disturbance similar changes may be 
found which may gradually disappear after an interval of rest. 

Some writers undertake to distinguish several varieties of shock. 
That variety of which a brief clinical picture has already been given 
is the most frequent, and is called by some the ' ' torpid form of 





Fig. 64. — Ganglion-cells from the Cord of a Cat : a, cell stimulated seven hours ; b, resting cell. 

shock. ' ' Travers in his account of shock uses the term ' ' prostra- 
tion with excitement," which was intended to describe a particu- 
lar form of shock. About this variety, which has frequently been 
mentioned by subsequent writers, there has been much discussion. 
Mansell-Moullin thus describes it: " The patient tosses wildly and 
vaguely from side to side as if frantic, complaining of a fearful 
oppression and want of breath, with presentiments of death and a 
feeling of total annihilation; often shouting again and again the 
same thing Xo encouragement is of any use: the conscious- 
ness is unclouded," etc. Cheever thus concisely defines this condi- 
tion: " Typhoidal delirium, a dusky flush over the malar bones, 
dull eyes, intermittent pulse, jactitations, exhaustion, death." 
Travers in his account of this condition quotes two illustrative 
cases, one of which appears to be an attack of acute mania follow- 
ing injury to a person who had previously been insane. The other, 
a rapidly-fatal case, closely resembles one of fat-embolism. 

In severe hemorrhage there is a peculiar restlessness which 
might show itself notwithstanding the accompanying shock, but 
hardly to such an extent as in this form of shock. There are, how- 
ever, cases where little or no bleeding has occurred when after 
an injury there is immediately great excitement. Mitchell has 
described graphically several such cases in his article on "Inju- 
ries of the Nerves." In one case of gunshot wound of the right 



SHOCK. 287 

wrist-joint, injuring the ulnar and median nerves and causing cere- 
bral excitement, the patient, who was a colonel, ran along the line 
of his regiment "half crazed,' ' in a state of wild excitement, and 
presently fell insensible, but not from loss of blood. In another 
case of shot-injury to the right median nerve the patient, also an 
officer, was helped to the rear, talking somewhat incoherently 
about matters foreign to the time and scene. He was very feeble, 
but lost little blood, and he had not the least remembrance of hav- 
ing been shot or. of any event which followed an hour afterward. 

Grceningen, although inclined not to accept this form of shock, 
suggests that it may be one following a condition of exaltation 
occurring after injury, and Roberts, speaking of delayed shocks, 
says: "Another explanation I venture to offer for some of those 
cases is the reactionary mental exhaustion that may occur after 
mental excitement and simulate shock." It is probable that some 
of these cases may be ascribed to that condition known as "delir- 
ium nervosum" or "delirium traumaticum." 

The so-called secondary or delayed shock may be due to sec- 
ondary complications ; it is probable that the term originated at a 
period when the pathology of fat-embolism or septic infection was 
less understood. In certain cases of shock the patient may some- 
times linger for one or two days before finally succumbing to 
exhaustion, and in this sense there may be such a condition, but 
it is usually called "protracted shock," and is hardly to be classed 
as a separate variety. 

Gross describes a variety known as insidious shock, which the 
writer thinks many surgeons will recognize as characteristic of 
true shock. The symptoms are of a marked character, however, 
and well calculated to deceive both patient and practitioner. 
"The person, though seriously injured, congratulates himself 
upon having made an excellent escape, and imagines that he is 

not only in no danger, but will soon be about again The 

countenance in this form of shock has often a peculiarly melan- 
choly expression, as if foreshadowing the fatal event; a sad smile 
plays upon the lips and illumines the lower part of the face, while 
the upper part wears a gloomy aspect in striking contrast with the 
other." It seems to the writer that in such cases there had been an 
attempt at reaction which had failed. The cheek may be flushed 
slightly and the skin be dry and warm; but the pulse, although 
stronger, is easily compressed, and it is evident to the careful 
observer that the patient's condition is most critical. He may 
greet you w T ith a cheerful ' ' Good-morning, doctor, ' ' and when 



288 SURGICAL PATHOLOGY AND THERAPEUTICS. 

asked how he feels will respond, ' ' Fine ;' ' and yet the fatal end 
may come only a few hours later. 

Several writers speak of local shock. Pirogoff mentions u la 
stupeur locale." Grceningen defines it as peripheral shock. It 
should not be confounded with the bruised and benumbed frag- 
ments of tissue in the immediate neighborhood of a wound. It 
seems to consist in diminution of sensation and of motion in the 
adjoining apparently healthy tissues, which is probably of central 
rather than of local origin. Gussenbauer claims to have seen this 
condition even when the symptoms of general shock have been 
very slight. It is analogous to some of the reflex paralyses so 
often observed, but in this case it is near rather than remote from 
the wound. Berger has noted in some cases a complete hemi-anaes- 
thesia involving not only the skin, but the adjacent mucous mem- 
branes. This anaesthetic condition is in some cases so marked that 
operations have been performed without pain. Many acts of hero- 
ism of this nature on the battlefield are mentioned by surgical 
writers. 

Among the most frequent causes of shock are the severe injuries 
which surgeons are accustomed to see in hospital practice. Among 
these injuries are the compound comminuted fractures of the bones 
of the extremities that are so frequent among railroad employes or 
machinists. Penetrating injuries involving the viscera are nearly 
always accompanied by considerable shock, though this primary 
condition must not be confounded with the septic disturbance 
which ofteii follows with great rapidity. Injuries of certain 
organs, as of the testicle and bone, are supposed to produce 
shock more readily than in other parts. A blow on, or the crush- 
ing of, the testicle may produce a certain amount of shock. Bris- 
towe reports a case of severe shock following a blow by a shot 
which grazed the testicle. Hunter mentions a sudden death dur- 
ing castration. Fischer reports the case of a fine healthy man who 
was attacked by an enraged horse. The testicle was seized by the 
animal, and the scrotum was held for a considerable time between 
the animal's teeth and severely lacerated. The man died in a few 
hours from shock. 

Operations upon the testicle, as conducted at the present time, 
are rarely followed by the symptoms of shock. Operations upon 
the urethra, such as catheterism, are often followed by syncope, but 
it is not in accord with the writer's experience that genuine shock 
can be produced by this cause. The very extensive operations 
which are now performed for necrosis do not seem to be followed 



SHOCK. 289 

by shock more frequently than any other operations of the same 
magnitude. All capital operations, particularly those prolonged 
over a considerable period of time, produce shock. Primary ampu- 
tations at the hip-joint were almost invariably fatal during the War 
of the Rebellion. The method then employed involved serious 
hemorrhage, which always greatly aggravates the condition of col- 
lapse due partly to the injury and partly to the operation. This 
operation was finally prohibited by the surgeon-general. 

According to Billroth, the evulsion of an arm or a leg is usually 
followed by a fatal shock. Fischer, however, relates the case of a 
lion-tamer whose whole left arm was torn from the shoulder-joint 
by a lion. The loss of blood was very slight, and the patient was 
so little affected by shock that he was able to walk to the hospital. 
Loss of blood is a powerful factor in the production of shock, and 
many of those cases which have terminated fatally may have been 
largely due to hemorrhage. The present "completed" operation 
for removal of cancerous breasts is likely to be followed by serious 
shock if this detail be not attended to. "The more sudden the loss 
of blood, the greater will be the immediate prostration and the less 
are the chances of recovery ' ' (Gay). 

Blows upon the chest are usually not followed by much shock, 
which is of short duration, and which is due as much to the gen- 
eral effects of the injury as to the local lesion. " The pit of the 
stomach ' ' or the abdomen is a much more sensitive region. 
Examples of shock from this form of injury are innumerable. 
Vincent relates the following case: "A man received a blow from 
a stick upon the epigastrium. He had an anxious expression and 
suffered from oppression, irregular heart-action, and shivering, 
symptoms which gradually disappeared during the day. In the 
evening his appetite returned, and he felt well: during the night 
he died without a struggle. At the autopsy there was absolutely 
nothing abnormal to be found." 

Blows received during football or baseball matches have termi- 
nated fatally with the same symptoms. Such cases remind one of 
the frog experiments of Goltz, and of Fischer's vaso-motor theory 
of shock. Doubtless many of these cases may be shown to owe 
their fatal termination to a weak heart. Grceningen attributes the 
shock in such cases to the peculiar anatomical distribution of the 
nerves to the abdominal viscera. Here are found the rich plexuses 
of the sympathetic system with the large ganglionic masses, most 
prominent among which is the semilunar ganglion, named by 
Bichat " le cerveau abdominal." A very powerful irritation may 

19 



290 SURGICAL PATHOLOGY AND THERAPEUTICS. 

suddenly be transmitted to the cord and the medulla oblongata, and 
the subsequent exhaustion of the vital nerve-centres may thus be 
produced. The writer is inclined to think, however, that a cer- 
tain number of these cases may be due to the vaso-motor disturb- 
ance produced by a temporary paralysis of the splanchnic nerves. 
This theory seems at least more closely in accord with physiologi- 
cal experiments. Such cases, therefore, should not be regarded as 
cases of true shock. 

Blows upon the neck often produce sudden collapse. There has 
already been alluded to the effect of a blow upon the pneumogas- 
tric nerve and the symptoms thus produced. In those cases under 
consideration, however, the patient drops vertically to the ground 
in an unconscious condition. Prize-fighters are well aware of the 
opportunity which a blow " upon the jugular " offers to save them- 
selves, perhaps, from a threatening defeat. Various theories have 
been offered to explain the nature of this injury. To some path- 
ologists it is known as concussion of the larynx. Fischer assumed 
that spasm of the glottis was thus produced. By Claude Ber- 
nard and others it is supposed that an inhibitory action is exerted 
upon the respiratory centre through an irritation of the superior 
laryngeal nerve. It is known that swimmer's cramp is produced 
by some such powerful stimulus sent to the respiratory centre, and 
it is probable that the sudden unconsciousness caused by garotting 
is produced in the same way. A blow in this region would also 
bruise the cervical sympathetic plexus of nerves, and it is possible 
that a sudden cerebral anaemia could thus be produced. It seems 
to the writer that many of these cases should be interpreted in this 
way and be removed from the category of shock. That true shock 
may, however, be thus produced seems apparent from cases reported 
by Maschka, of which the following is an example: A boy, twelve 
years of age, received a blow from a stone upon the anterior por- 
tion of the larynx. He fell lifeless to the ground. At the autopsy 
no local lesion was found and no injury elsewhere. The sudden 
death may be attributed in this case, in part, to shock and in part 
to cerebral anaemia. 

In severe burns which have affected more than one-third the sur- 
face of the body the symptoms of shock are always well marked. 
It has been suggested that extensive dilatation of the blood-vessels 
upon the surface of the body causes diminution of blood-pressure, 
and that the heart's action is thus weakened. Billroth attributes 
the symptoms to shock produced by the severe irritation of the 
nerve-centres through the peripheral nerves, and it is probable that 



SHOCK. 291 

the condition of such individuals is one of true shock. Similar 
results, according to Gay, may be produced by swallowing irrita- 
ting poisons, as oxalic acid or corrosive sublimate. The constitu- 
tional effects of such poisons as prussic acid or nicotine or the 
poison of serpents should be regarded as collapse due to the action 
of the poisons rather than to true shock. Sudden death from light- 
ning is also due to shock. Grceningen reports the case of a sol- 
dier who recovered from lightning-stroke in whom the symptoms 
of shock were well pronounced. 

Cases of sudden death often follow the tapping of cysts, particu- 
larly in the abdominal cavity. Many of these cases should be 
regarded as local hyperemias due to the sudden removal of pressure 
from the abdominal blood-vessels. In some cases when the aspira- 
tor has been used air has unintentionally been forced into the veins 
and an embolism thus produced. Moullin reports a case of death 
in five minutes after tapping the liver for hydatid disease. The 
only sign of organic disease found at the autopsy was a slightly 
granular condition of the kidneys. 

The sensitiveness of the abdominal cavity has already been 
mentioned. In abdominal operations shock may be produced and 
he aggravated by prolonged handling of the intestines and the 
breaking up of extensive adhesions, and the exposure of the viscera 
to the air, whereby a great amount of heat is rapidly lost. Great 
shock is caused by a rupture of the viscera, particularly of the 
intestines. In strangulated hernia the symptoms of shock are 
often present in a marked degree. Even after the constriction has 
been relieved fatal shock may supervene. This peculiar condition has 
been recognized by French writers under the name of peritonisme 
or cholera herniare. According to Mansell-Moullin, the strangula- 
tion of a portion of the small intestine, whether in a hernial sac or 
"by some band within the abdominal cavity, is attended at once by 
symptoms of the most complete prostration, and may of itself, if 
left unreduced, be sufficient to occasion death without the produc- 
tion of peritonitis. 

The relation of pain to shock has been noticed by many writers. 
Before the days of anaesthesia such a case as the following, reported 
by Sir Astley Cooper, seems to have been a not unusual occurrence: 

A brewer's servant, a man of middle age and robust frame, suffered much 
agony for several days from a thecal abscess occasioned by a splinter of wood 
penetrating beneath the nail of the thumb : a few seconds after the matter 
was discharged by a deep incision the man raised himself by a convulsive 
effort from his bed and instantly expired. 



292 SURGICAL PATHOLOGY AND THERAPEUTICS. 

If it is recalled for a moment what has been said about the dif- 
ferent degrees of nerve-irritation, it will be found that very power- 
ful nerve-irritation, such as usually produces shock, is painless. 
The higher degree of irritation destroys function. For this reason 
wounds received during battle are not painful. Stromeyer states 
that nothing is so surprising to the novice in military surgery as 
this absence of pain. ' ' Perfect quiet reigns in the hospital ward the 
first night after a battle. ' ' 

That anaesthesia has served to lessen shock after operations is 
probably due to the fact that the nerve-centres are thus protected 
to a certain extent from powerful irritations from without, rather 
than to the mere absence of pain. L,e Gros Clark says: "I think 
the shock of pain is much overestimated: .... it is certain that 
great and almost continued pain is compatible with protracted 
life." Grceningen maintains that the theory that shock is caused 
by pain has not been proven. 

Mental emotion is accepted by many writers as a cause of shock, 
but the theory is received with doubt by others. The following 
case, reported by L,auder Brunton, has been much quoted: 

Many years ago the janitor of a college had rendered himself obnoxious 
to the students, and they determined to punish him. Accordingly they pre- 
pared a block and an axe, which they conveyed to a lonely place, and, having 
dressed themselves in black, some of them prepared to act as judges and sent 
others of their company to bring him before them. He affected at first to 
treat the whole thing as a joke, but was solemnly assured by the students 
that they meant it in real earnest . He was told to prepare for immediate 
death. The trembling janitor looked all around in the vain hope of seeing 
some indication that nothing was really meant, but stern looks met him 
everywhere. He was blindfolded and made to kneel before the block ; the 
executioner's axe was raised, but instead of the sharp edge a wet towel was 
brought smartly down on the back of the culprit's neck. The bandage was 
now removed from his eyes, but, to the astonishment and horror of the stu- 
dents, they found that he was dead. 

Such a case may be due to heart failure from fear and excite- 
ment. It is generally conceded, however, that all depressing 
influences, whether moral or physical, contribute to the aggrava- 
tion of shock. Soldiers exhausted from great fatigue or from star- 
vation or demoralized by defeat succumb much sooner to shock 
than do their victorious opponents. 

The effect of individual temperament is often strikingly shown 
after severe injuries. Soldiers of the most undaunted courage turn 
pale and tremble like a leaf after a comparatively trifling accident 
(Gross). Mitchell reports the case of an officer wounded in the heel 



SHOCK. 293 

who was instantly thrown into a condition of the utmost trepida- 
tion. His character for courage was undoubted, and a court of 
inquiry, for which he asked, cleared him on the surgical evidence. 

Railway injuries are supposed to be a prolific source of shock 
even in cases where there has been no well-defined external or 
internal injury. This class of cases, formerly regarded as due to 
concussion of the spine, has been more recently interpreted by 
Page as a shock to the nervous system in which a condition is 
eventually arrived at where the seat of the disturbance seems to be 
centred in the will-power rather than in any lesion of the nervous 
system. Cases of this kind may or may not at the time of the acci- 
dent present the symptoms of true shock. "It is a singular fact 
that cases attended by symptoms of shock immediately after an 
accident seldom present the symptoms peculiar to ' shock to the 
nervous system ' ' (Gay). The subsequent chronic state of the 
patient should not be confounded with true shock, but is more 
closely allied to the condition now known as neurasthenia. 

Age and sex are supposed to have an influence in producing 
shock, but it is not probable that there is any material difference in 
this respect. In youth, as in old age, the nerve-centres probably 
yield more readily to powerful irritations, and this may also be said 
of persons whose constitutions are enfeebled by alcohol or by 
disease. 

Great precautions should be taken during the performance of 
capital operations upon very young children as well as upon the 
aged, and the condition of the heart and kidneys should always be 
inquired into in all cases before operation. At one time it was 
supposed that individuals in robust health were not so well pre- 
pared to undergo a severe operation like amputation of the hip- 
joint as those who were already somew T hat invalided by disease. 
In the former class of cases there is usually the history of a severe 
accident with its attendant shock and hemorrhage. Obviously in 
the second class of cases the operation would be performed with 
all the advantages that a previous preparation of the patient could 
give. 

There have already been briefly alluded to the symptoms of shock 
in a typical case. The most striking of these symptoms to the 
observer is the sickly-white hue of the skin, the thin, pale lips, and 
the contracted features: the expression of the face is frequently so 
altered that it is difficult to recognize a friend. The pupils are but 
slightly altered, but the eyes are sunken in their sockets. The sur- 
face of the body is cold everywhere to the touch, the hands are 



294 SURGICAL PATHOLOGY AND THERAPEUTICS. 

blanched, and the fingers and nails exhibit a bluish color. The 
sensation of pain is more or less diminished, but a disturbance of 
the crushed limb will cause the patient to emit a feeble and hoarse 
cry. 

Muscular action is greatly enfeebled, so that voluntary move- 
ments are made but seldom. The excito-motor functions in severe 
shock are gravely impaired. The lids do not close when the con- 
junctiva is irritated. Deglutition is difficult. The anal sphincter 
is relaxed, while the urine is retained. ' ' Under such circumstances, 
especially when the fifth and glosso-pharyngeal nerves fail to excite 
any response in the nerve-centres, the gravest fears may be enter- 
tained that respiration itself will momentarily yield" (Jordan). 
The inspirations are shallow, but are occasionally accompanied by 
sighing and convulsive tremors. 

There is no coma, but the mental condition is one of more or 
less sluggishness, due doubtless to the central anaemia. The con- 
dition of the pulse varies with the degree of shock. In the milder 
forms it is frequently slower than normal, but it is more compres- 
sible. In the graver forms it is small, fluttering, and at times almost 
imperceptible. The thread-like pulse is under these circumstances 
usually more rapid than normal, the heart apparently endeavoring 
to compensate by frequent action for the feebleness of the current. 
The strength of the pulse is a most important guide to the surgeon 
in estimating the severity of the shock. A more accurate gauge 
of the degree of shock is to be found in the temperature. To 
determine this point the thermometer should be placed in the rec- 
tum, and if a fall of two degrees below the normal point is regis- 
tered, the amount of shock is sufficient to contraindicate operative 
interference. Much lower temperatures have been recorded from 
observations taken by placing the thermometer in the axilla. The 
secretions are often much diminished or are altered in their cha- 
racter. The urine is scanty; the catamenia may suddenly cease or 
may appear. Many writers relate instances of suppression of lac- 
tation. A woman suddenly threw herself between two soldiers to 
save the life of her husband. The chemical condition of her milk 
was so altered immediately after that the child at the breast was 
poisoned by it. The great amount of cold sweat upon the forehead 
has been explained by the relaxation of the mouths of the sweat- 
ducts. Vomiting is regarded by some as the primary sign of 
reaction. One of the first evidences of this change is the return- 
ing color of the face and the strengthening of the heart's action. 
Formerly it was supposed that the symptoms now recognized as 



SHOCK. 295 

traumatic fever were simply due to the rebound of the system from 
the condition of shock, and that they were to be expected as a 
natural sequence. Reaction is, however, in reality, simply a return 
of the system to its normal condition. The various functions 
should therefore, in a case which has been treated antiseptically 
or where no wound was present, reappear in their natural state of 
activity. The pulse becomes stronger and fuller, the skin dry and 
warmer, and the respirations are deeper. The mind regains its 
self-possession, and the temperature returns to the normal standard. 

In making the differential diagnosis there are many conditions 
formerly attributed to shock to be considered which now are recog- 
nized as due to other causes. It is only in the gravest forms of 
hemorrhage that the patient's condition is likely to be mistaken 
for one of shock. The anaemia from loss of blood can readily be 
distinguished from shock, as it comes on gradually, perhaps, from 
recurring hemorrhages, and is an affection of a more chronic type. 
When, however, the patient succumbs to bleeding from some large 
vessel or in consequence of the laceration of numerous vessels in 
some extensive wound, his condition very closely resembles that 
of shock. John Bell has given a vivid picture of such a case: 
"The face becomes all at once deadly pale, the circle around the 
eyes is livid, the lips are black, and the extremities are cold. The 
patient faints, recovers, and faints again, with a low, quivering 
pulse; he has nausea, and his voice disappears. There is an 
anxious and incessant tossing of the arms with restlessness, which 
is the most fatal sign of all. He tosses continually from side to 
side; his head falls down in the bed; at times he suddenly raises 
his head, gasping for breath, with inexpressible anxiety; the toss- 
ing of the limbs continues; he draws long and convulsive sighs; 
the pulse flutters and intermits with the breathing more and more, 
and he expires." The prominent distinctive features of hemor- 
rhage are the anxious expression of the face, the tossing about 
of the arms, the great restlessness, and the frequent attacks of 
syncope. 

Acute septic poison, particularly that occurring after operations 
or injuries of the abdominal cavity, presents frequently a group 
of symptoms which might readily be mistaken for shock. A per- 
foration of the intestine may have taken place, or a gunshot injury 
of the bowel has permitted the escape of the contents of the intes- 
tine into the peritoneal cavity. In a few moments' time the 
appearance of the individual changes and the symptoms of col- 
lapse are well marked. 



296 SURGICAL PATHOLOGY AND THERAPEUTICS. 

In fat-embolism there exists another cause of sudden death 
after injuries. Fluid fat may be taken into the open vessels and 
be carried by the lymphatics into the circulation. Fractures of 
bones furnish the most typical example of this complication, as do 
also ruptures and contusions of the liver and severe contusions of 
the skin and subcutaneous fat. Acute suppurations in tissues rich 
in fat may also produce fat-embolism. It is also found in a greater 
or lesser degree in acute osteomyelitis. The most frequent seat 
of these emboli are the lungs. After reposing for a brief time in 
the vessels of the lung, the fat-drops are carried onward and dis- 
tributed to various organs, such as the heart, capillaries, skin, 
brain, muscles, and kidneys, whence they finally disappear. It 
is only when large amounts of fat accumulate in this way in the 
capillaries of the lung that a fatal result is brought about. The 
symptoms of this complication, which occurs within twenty-four 
or forty-eight hours after an injury, are sudden pallor, irregular 
heart-action, dyspnoea, perhaps haemoptysis, or convulsions and 
death. Fat will be found in the urine. 

The presence of air in the vessels in small quantities has been 
shown by experiment not to be injurious, but when a large quan- 
tity has been introduced during a surgical operation the heart may 
be filled with air, and then is unable to contract. Death under 
such circumstances will be instantaneous, and will be attended 
with the symptoms of syncope. This extremely rare occurrence 
can only happen, according to Hare, when a pint or more of air 
has been introduced at once into the circulation. 

Fainting or syncope is regarded by Travers as differing only in 
degree from shock. It has already been shown that syncope is due 
to disturbances of circulation only. Preliminary nausea, ringing 
in the ears, and dizziness, followed by a fainting fit, during which 
the patient is temporarily unconscious, are symptoms of acute cere- 
bral anaemia, and not of shock. In concussion of the brain there 
are, according to Fischer, an arterial anaemia and venous stasis. 
The experiments of Koch and Filene showed no central lesion, 
and they conclude that the vaso-motor centre is not only affected, 
but that all other cerebral centres of activity are temporarily ex- 
hausted and paralyzed. There is here a condition closely resem- 
bling that which in the cord and medulla is called "shock." 
Some writers, however, point out that there must be some phys- 
ical change, for the brain is never fully restored to its former con- 
dition, as the memory of what has happened immediately before 
the injury never returns, and in this respect concussion differs 



SHOCK. 297 

from shock in its nature. Duret has, in fact, observed a lacera- 
tion of the floor of the fourth ventricle, due to the forcing of the 
cerebral fluid from the lateral ventricles through the aqueduct of 
Sylvius, which is thus dilated, into the fourth ventricle. The 
symptoms of concussion are, however, essentially different from 
those of shock: there are both insensibility and a slow and full 
pulse, symptoms which are sufficiently characteristic. 

The prognosis of shock is uncertain and doubtful. Shock may 
be fatal within the space of a few seconds, or the patient may live 
one or two days and finally die. According to Cheever, if reaction 
does not set in within eighteen hours after the injury, it never 
comes. Among the symptoms that enable us to judge best of the 
patient's condition may be mentioned, first, the pulse, which can 
be examined with the least disturbance of the patient. A patient 
may live in a pulseless condition for several hours, but if appro- 
priate remedies and nursing fail speedily to restore a semblance of 
pulsation at the wrist, the condition of the patient may be regarded 
as most grave. Perhaps a more accurate guide, on account of its 
independence of the emotions of the patient, is the temperature. 
To determine the temperature properly the thermometer should 
be placed in the rectum. A temperature of 96 F. is regarded 
by Redard as indicating severe shock, and is one which contra- 
indicates any surgical operation. 

Loss of power in swallowing is considered a symptom particu- 
larly unfavorable. This indicates, according to Mansell-Moullin, 
an inhibition of the glosso-pharyngeal centre, which is in the 
immediate vicinity of other vital centres. The same import may 
be attributed to insensibility of the conjunctiva, indicating that 
the fifth pair of nerves is also implicated. Persistent vomiting, 
showing great irritability of the stomach, and relaxation of the 
sphincters, are signs that a fatal termination is close at hand. 

Fortunately, in many cases much can be done toward the pro- 
phylactic treatment of shock. Cheever calls attention to the 
relation of the operative procedures of modern surgery to shock, 
and raises a warning voice against many of its attendant dangers. 
Operations under anaesthetics, often needlessly prolonged, are ex- 
hausting, and modern dressings are apt to be tedious and chilling. 
Great care should be taken against exposure of the patient, and a 
special costume is often advisable for the proper protection of the 
trunk or of the extremities. 

Wet cloths and irrigations favor evaporation and rapid loss of 
heat. The axillae, the thorax, and, above all, the abdomen, are 



298 SURGICAL PATHOLOGY AND THERAPEUTICS. 

especially prone to deleterious chilling. The prolonged exposure 
or the handling of certain organs, such as the brain or the intes- 
tines, is liable to produce shock. If a capital operation is to be 
performed upon a feeble subject, even* detail of the operation 
should carefully be planned beforehand, and a systematic effort 
should be made to reduce to a minimum the time consumed in 
moving the patient from his bed to the operating table and back 
again. Many details which on ordinary occasions seem important 
should be sacrificed to the more important element of time. The 
scale may be turned at the last moment against a patient who has 
successfully endured the ordeal of an amputation at the hip-joint 
by. too much attention on the part of the surgeon to some elaborate 
detail of suture. kk The old method was a matter of minutes : now 
it is one of hours" (Cheever). Inasmuch as many of the features 
of aseptic surgery have been simplified, may we not aspire to add 
to modern skill the speed of a former generation ? 

The moment when to operate in a case of shock is a point in 
which the practice of different surgeons differs greatly. In cases 
of severe shock it is manifestly bad surgery to add the shock of an 
operation to that already existing, but it is often a question whether 
the presence of a mangled and bleeding limb does not retard or pre- 
vent reaction. While waiting for operation the patient lies upon 
the table, the limb is encircled by the tourniquet, and the repose 
and care so important to him at such a crisis cannot be obtained. 
More harm, however, is done by early operations than by prolonged 
waiting. A few hours of such rest and treatment as can be obtained 
often enables the patient to regain sufficient power to carry him 
safely through the ordeal of an operation. 

Whatever is done at this time should be so planned as to avoid 
scrupulously all unnecessary fatigue. Rough handling and fre- 
quent shifting of the patient are manifestly out of place ' ' when a 
feather turns the scale." Paget says : " There is perhaps no case 
in the management of which the courage to do little is more needed. 
Great energy of treatment may do great mischief." 

The patient should be placed as quietly and as gently as possible 
on the bed where he is to remain permanently until reaction is 
established. The foot of the bed should be raised, so that the weak 
heart may be able to nourish the exhausted vital centres with blood. 
Next in importance to perfect rest is the application of heat to the 
body. Hospital operating tables should be so arranged that diffused 
heat may be brought in contact with the patient during the opera- 
tion and the previous period of waiting. Heat should be applied 



SHOCK. 299 

to the extremities and to the neighborhood of the heart. Great 
care should be taken, particularly in the case of the patient under 
anaesthesia, to avoid burning the skin. An arrangement by which 
dry heat could be conveyed from the hot-air register to the bed 
itself would accomplish this object better than in any other way, 
and would have the great advantage of avoiding disturbance of the 
patient. 

In cases of severe shock it is thought advisable by some to per- 
form u auto-transfusion;" that is, to bandage the extremities so 
that the circulation may be limited to a confined area where the 
organs most essential to life are situated. Such a method involves 
dangerous handling, and its employment should be advised in 
exceptional cases only, when other and better remedies are not 
available. 

Transfusion is now abandoned, but there may be resorted to, in 
cases of shock attended with great loss of blood, infusion of a warm 
salt solution: 

Sodii chlorid., 3iss. 

Sodii bicarb., gr. xv. 

Aq. dest, Oij.— M. 

The salt solution may be introduced either into the median cepha- 
lic vein or into the loose subcutaneous tissue of the abdominal walls. 
Patients endeavor to supply the deficiency of fluid at the vital centres 
by drinking large amounts of water. If the water is well borne, there 
is no objection to its use, but in an irritable condition of the stomach 
it is not likely to be retained. 

Enemata of water are very valuable under these circumstances. 
Mumford recommends hot enemata of a weak salt solution. A 
quart might be given, and be repeated in half an hour. The solu- 
tion in the exsanguined state of the patient is absorbed with aston- 
ishing rapidity from the lower bowel. Lange administers a pint 
of water of the temperature of the body, with the addition of some 
stimulant, mostly claret, during long operations. This allows of 
absorption before it is too late. L,ater, there may be given nutrient 
enemata largely diluted — peptonized beef-juice, milk, and eggs — 
up to four or five ounces, with the addition of half a pint or more 
of warm water. The enema should be administered through a 
flexible catheter attached to a short rubber tube and funnel. By 
this means high injections may be given. 

Stimulants given by the stomach should form an important ele- 
ment in the treatment of shock. To strengthen the heart's action, 



300 SURGICAL PATHOLOGY AXD THERAPEUTICS. 

and at the same time to relieve nausea, black coffee should be given 
in small and frequent doses; it may be given alone or in conjunc- 
tion with brandy. In giving alcohol care should be taken not to 
overload the stomach. Champagne or brandy and soda is often 
well borne. Brandy may be injected hypodermically when the emer- 
gency is great, but it should not be regarded as a matter of routine, 
and should only be used when other and more efficient means of 
stimulation, such as have already been mentioned, cannot safely be 
employed. The writer is somewhat sceptical as to the absorption 
of remedies injected into the subcutaneous tissue of an extremity 
during severe shock. The thick fatty layers which underlie the 
integument of the thorax and abdomen are more suited for hypo- 
dermic medication. 

Of drugs, opium is probably the most valuable. In small doses 
it is stimulating, and it brings about a condition of repose which 
is of the utmost value. It should be given subcutaneously or by 
the rectum. Digitalis is also a powerful cardiac restorative: as it is 
not usually well borne by the stomach, it may also be administered 
subcutaneously or by enema. It should be given in large doses 
if used at all. Xitro-glycerin also strengthens a failing heart. It 
may be given in doses of -^inr g r - an d is often of service when digi- 
talis fails to produce the desired result. Strychnine may be placed 
upon the list of drugs available in such emergencies: it is highly 
prized by Grceningeu. A good diffusible stimulant is aromatic 
spirits of ammonia, which has the advantage of being well borne 
by the stomach. It is a useful drug to employ in the least grave 
forms of shock. 

Remember alwavs that the condition the surgeon has to deal 
with is one of exhaustion, and that rest is needed for repair. 



XII. FEVER. 

To have a clear understanding of the nature of the process 
known as fever, it will be necessary, first, to study the laws gov- 
erning the mechanism which maintains the human body at a con- 
stant temperature. The normal temperature of a human being in 
a state of health is 37 ° C, or 98. 4 F., and it possesses this pecu- 
liarity, that under most varied conditions, in the tropics and in 
arctic regions, there is an extremely slight variation from these 
figures. The stability of temperature observed in man is shared 
by birds and mammals, and the arrangement by which this standard 
is preserved is known as thermotaxis or heat-regulation. 

The body constantly produces heat by a process of combustion, 
oxygen being introduced into the tissues and carbonic acid being 
eliminated. Enough heat is thus manufactured to raise the tem- 
perature of the body i° C. in half an hour. Were there not at 
the same time a corresponding loss of heat, the temperature would 
rise 48 ° C. in twenty-four hours — a height which would be incom- 
patible with life. 

To maintain a proper temperature it is necessary, therefore, that 
there should not only be a given production of heat and provision 
made for a continuous dissipation of the same, but there must also 
exist a mechanism by which the two processes are balanced, so that 
the temperature shall remain at its normal height. 

If the production of heat should at any time exceed the loss, 
the temperature would immediately rise; if the production should 
happen to be less than the amount given oft, there would be a fall 
of temperature. As a matter of fact, both of these processes are 
subject to considerable variation. After taking food there is an 
increase in the amount of heat produced, and a still greater increase 
after muscular exercise; during rest and sleep the amount produced 
is somewhat diminished. Under similar conditions there is a cor- 
responding change in the amount of heat that is given off from the 
body. The flushed face of one who has just risen from a luxurious 
repast, the warmth and moisture of the skin and the increased res- 
piration following active exercise, are indications that the regu- 
lating process is at work, and that the increased heat-production is 

301 



302 SURGICAL PATHOLOGY AND THERAPEUTICS. 

being offset by the cooling down of the unusual amount of blood 
exposed on the surface to the influence of the surrounding air and 
by the increased evaporation. 

In estimating the temperature of the body, particularly when 
making scientific experiments, it is important to remember that all 
parts are not equally warm. The body may be likened to a heated 
globe whose centre has a uniform temperature: a thermometer 
introduced gradually will grow warmer until it reaches this central 
point, when the temperature will become constant. The surface 
will have a considerably lower temperature, owing to the cooling 
process which is going on, and between the two there will be an 
intermediate layer whose breadth will vary according to the amount 
of cooling down the globe is subjected to. These inequalities are 
greatly modified by the circulating blood. If there has been an 
increased amount of heat produced, the warmer blood will, on 
coining to the surface, expend some of its heat in warming up this 
layer, and will further be cooled by contact with the surrounding 
cooler medium. 

It appears, therefore, that there is an automatic arrangement 
which seems to protect the human body from the ordinary changes 
to which it is daily subjected; but that this works only within cer- 
tain limits is evident from the artificial aids which are necessary to 
man to keep the temperature normal. Light clothing and cooling 
drinks favor heat-elimination when the atmosphere is unusually 
warm : the cool water taken internally not only lowers the tempera- 
ture of the interior slightly, but also furnishes abundant fluid to 
facilitate evaporation from the surface. Further protection is 
given also to animals in the varying thickness of their furry coats 
or in their adipose tissue according to the necessities of the climate 
or the season. Some animals are less able to preserve their normal 
temperature than others, cats and rabbits being killed easily by 
cold baths. The equilibrium is less stable in children than in 
adults. 

It will be seen that the change in the calibre of the vessels on 
the surface of the body is an important factor in the regulation of 
the temperature in man. In a heated atmosphere the vessels 
are dilated, the skin becomes unduly warm, and active perspira- 
tion takes place. If the air be dry, evaporation will be favored 
greatly, and man is thus able to bear for a short time tempera- 
tures so high that it was at one time supposed that the power to 
produce cold existed in the body. 

If an animal is placed in a chamber heated to from 32 ° to 36 



FEVER. 303 

C great increase of respiration and heart-pulsation will be 
observed; also dilatation of the vessels of the skin, as may be 
seen in its ears and in other places. In a temperature of from 
42. 2° to 42. 8° C. there is an enormous increase of respiration, the 
pulse cannot be counted, all the vessels are dilated, and all the 
muscles are relaxed; the pupils are also dilated. If kept long in 
this temperature, death occurs from paralysis of the heart and the 
vessels. Removal of the animal to a cooler atmosphere before 
death will be followed by sinking of the temperature below nor- 
mal. This fall of temperature is due to the great dilatation of 
the superficial vessels, causing an excessive loss of heat. The 
low temperature observed after excessive burns is caused in this 
way, the dilatation of the cutaneous vessels being very complete, 
owing to the destruction of all muscular action in them. It is 
probably some such disturbance of the circulation that occurs 
previous to "catching cold," the dilated vessels on the surface 
allowing the blood which goes to the internal organs to become 
suddenly cooled. Anything that tends to weaken the contractility 
of the vessels^ like too great care in protecting the surface of the 
body, would favor catching cold; whereas cold bathing exerts a 
protective action by restoring the tonus of the vessels. The time 
of the year when sudden changes of temperature occur, as in the 
early spring, is prolific in such affections, rather than in winter, 
when the cold is continuous. Although the symptoms produced 
by the long-continued high temperature resemble fever, yet the 
condition is not fever, for the temperature found to exist in these 
experiments is due to the storing up of heat in the body owing 
to a diminished loss, and not from an increased production. The 
increased chemical changes of fever are also not present. 

On exposure to cold under ordinary conditions the skin becomes 
cooled and the heat-dissipation is considerably interfered with, as 
less moisture is now exhaled; and when the degree of cold is 
unusual the shivering bears evidence to marked muscular con- 
traction taking place, notably in the muscles of the skin and in 
the blood-vessels, the skin becoming shrunken and the condition 
known as goose-flesh being produced. If the loss of heat is not 
sufficiently checked in this way, active muscular exercise will 
favor a restoration of the normal temperature by an increased 
production of heat. If a large amount of heat is suddenly 
abstracted from the body, as in a cold bath, the usual mechanism 
which regulates the heat-loss will not be sufficient to maintain the 
temperature, and it is interesting to find that under these circum- 



304 SURGICAL PATHOLOGY AND THERAPEUTICS. 

stances as much as three or four times the normal amount of heat 
may be produced. The prompt reaction that follows the cold bath 
in healthy individuals is probably due to this fact. The regula- 
tion of heat-dissipation is effected by the vaso-motor apparatus: 
this is partly accomplished by the direct action of the changes of 
the temperature upon the surface of the body and partly by reflex 
action through the sensitive nerves. The dilatation of the vessels 
in a heated skin is evidently due to a vaso-motor paralysis, but 
the profuse perspiration which accompanies it is not so easily 
explained. Whether to ascribe it to hyperaemia of the sudorip- 
arous glands or to stimulation of special nerves presiding over 
their functions remains still to be determined definitely. 

Given a steady production of heat, regulation is effected by 
varying the amount of heat eliminated from the body; but if 
there is a long-continued or excessive loss of heat, as in the 
experiment of the cold bath, then regulation must be effected 
by increasing the amount of heat-production. L,et the atten- 
tion therefore now be turned to the sources of heat-production in 
health. 

Many experiments show that muscular action is followed by an 
increase of temperature in the muscles. They constitute nearly 
one-half the whole mass of the body, and are said to produce 
four-fifths of the heat in health, and even more in fever. A 
comparison of the electrified and the quiescent nerve indicates 
the power of nerve-tissue to produce heat. Glands at the time 
of their function are a fruitful source of heat. It is generally 
conceded also that in all tissue heat is produced during the assimi- 
lation of nutritious material. Of these tissues, the muscles must 
be regarded as the chief source of heat, for in them the oxidation 
is most active. Even when at rest a large amount of carbonic 
acid is found in the venous blood which comes from them, and 
during severe muscular action the amount of carbonic acid exhaled 
may be increased five-fold. 

There has already been mentioned an increased production of 
heat in the cold bath; that is, when a large amount of heat is sud- 
denly abstracted from the body. This has been explained by an 
irritation of the peripheral nerves through change of temperature 
of the skin, producing a reflex action on the nerves going to in- 
ternal organs, which nerves probably bear some relation to the 
oxidation-processes. The tissue-metamorphosis — or metabolism, as 
it is sometimes called — in the muscles at rest is not only affected by 
cold, but it can also be increased by strychnine and other irritants, 



FE VER. 305 

and can be diminished or stopped entirely by curare. This drug 
paralyzes the terminal fibres of the nerves and thus deprives the 
muscles of their innervation; hence the bright arterial color of 
venous blood and the diminished gas-changes in curarized ani- 
mals. In cases of paralysis the tissue-change in muscles is 
markedly affected. 

The idea of an increase in the amount of heat-production 
through the nerves is not a new one. It is a well-known clinical 
fact that injuries to the upper part of the cord have been followed 
by a fall of the temperature below normal: in a case of crushing 
of the cord at the fifth cervical vertebra, reported by Hutchinson, 
the temperature fell to 93 F. In a case of injury in the me- 
dulla the temperature rose as high as no° F. In cases of paral- 
ysis trifling disturbances, such as those of digestion, will cause an 
excessive rise of temperature for a short time. In cerebral hem- 
orrhage and tumors of the brain there occasionally is a rise of 
temperature without other evidence of inflammation: just before 
and immediately after death there may be an excessive rise, the 
temperature exceeding 108 F. 

Urethral fever has long been cited as an example of febrile dis- 
turbance produced by reflex action as the result of local irritation. 
When the vaso-motor nerves were studied by Claude Bernard, he 
thought that the sympathetic was a check-nerve to heat-produc- 
tion, and that the chorda tympani had the opposite function. He 
therefore called them "thermic nerves," supposing them to influ- 
ence directly the production of heat going on in the tissues. Brown- 
Sequard showed, however, that the local rise of temperature in 
Bernard's experiments was due to the increased flow of blood to 
the part, and that no production of heat consequently took place. 

These observations led to a series of experiments to determine 
whether there existed a special set of nerves which presided over 
the production of heat, the so-called " excito-caloric nerves." The 
vaso-motor centre has been placed in the lower part of the floor of 
the fourth ventricle by Wood and others, and it is also said by 
some writers to be situated in the anterior portion of the lateral 
columns. The best authorities are as yet divided on the question 
of the existence of a special set of thermic nerves, to say nothing 
of thermic centres, but the general drift of opinion is at present set- 
ting strongly in favor of such an apparatus presiding over the pro- 
duction of heat. Ott claims to have discovered four heat-centres. 

Some recent observations in England have thrown light upon 
the mode of action of these nerves in producing heat in the muscle. 
20 



306 SURGICAL PATHOLOGY AND THERAPEUTICS. 

MacAlister has succeeded in separating the heat-producing or ther- 
mogenic function of the muscle from its motor function. By elec- 
tric stimulation of the sciatic nerve of a frog he was able to record 
the rise of temperature produced simultaneously with motion. It 
was found after repeated stimulation that the thermometer showed 
no rise in temperature, while the motive power was still unimpaired. 
The same independence of the thermogenic from the motor func- 
tion was observed in warm-blooded animals by experimenting with 
the influence of cold on the muscles. He concludes, therefore, 
that the metabolism by which motion takes place and that which 
results in the thermogenic function are different. The ' ' contrac- 
tile, stuff " of the muscle is not the same as its " thermogenic stuff." 
They act differently to stimulation, to repairing influences, and to 
cold. 

The thermogenic material which a muscle contains is conse- 
quently acted upon by nerves which keep up a process of innervation 
hi the muscle whether at rest or in motion. 

Gaskell has undertaken to show that this process of innervation is of a 
double character. He found, on the one hand, that the action of the motor 
nerves on the muscular fibres of the heart produced contractions (by means 
of chemical changes in the muscle) which are of a destructive nature ; 
repeated action exhausts the "contractile stuff." On the other hand, stim- 
ulation of the vagus or inhibitory nerve is restorative : there is a repair of 
function of the muscle ; the chemical changes are in this case constructive. 
The former action is called " catabolism," the latter " anabolism," or assimi- 
lating or trophic action. It is the stimulation of these nerves by change 
of air, agreeable surroundings, and other favorable conditions that promotes 
repair of the tissues and increases the appetite and weight. He infers that 
the thermogenic tonus of the muscle is preserved in the same way by two 
opposing innervations, the one tending to build up the thermogenic stuff, and 
the other disintegrating it by the process of oxidation. Further, Gaskell 
found, on stimulating the motor nerve of a quiescent muscle, that the con- 
tracted muscle assumed an electrical condition different from that of the 
uncontracted or negative variation, and that when the inhibitory nerve is 
stimulated the muscle exhibits a positive variation. It is possible that fur- 
ther experiment will show that on stimulating the motor nerve there will be 
an evolution of heat, and on stimulating the inhibitory nerve the muscle will 
become cooler. 

From these observations MacAlister concludes that the muscles of the body 
have their double nerve-supply. ' ' The one set of fibres are essentially cata- 
bolic : they set up disintegrative changes in the muscle, which are manifested 
first by thermogenesis, and secondly by contraction. The other set of fibres, 
whose path is perhaps anatomically different, are essentially anabolic : they 
set up reconstructive changes in the muscle which are manifested by inhibi- 
tion of motion on the one hand and absorption of energy on the other. ' ' 

It is thus seen that the normal temperature of human bodies is 



FEVER. 307 

maintained by the heat produced from the chemical changes which 
result from the innervation of the tissues, and particularly the mus- 
cles, consisting mainly in the absorption of oxygen and the elimi- 
nation of carbonic acid. The nervous mechanism presiding over 
this function is probably somewhat analogous in its action to that 
of the vaso-motor system, by means of which the elimination of 
heat from the body is effected. The stability of air-temperature is 
largely maintained by variations in the amount of heat-dissipation, 
consequently by changes in the circulation in the surface of the 
body and by evaporation from the skin and the lungs. Changes in 
heat-production are occasionally also brought about by reflex 
action. Whether this action is accomplished through a special 
regulating centre is doubtful: it is more probable that the nervous 
action thus aroused is exerted through thermic nerves than through 
the vaso-motor system, as many good observers still suppose. 

The reader is now prepared to consider the nature of that form 
of constitutional disturbance which is accompanied by the group 
of symptoms associated with the name of fever. The most promi- 
nent and constant of these symptoms is the rise of temperature. 
Although it has long been recognized that the body was warmer in 
fever, and although as early as the last century it was discovered, 
by means of a Fahrenheit thermometer, that the temperature was 
raised even during a chill, it is only within the recollection of the 
present generation of physicians that systematic measurements of 
the temperature were undertaken, and that the relation of pyrexia 
to fever became generally recognized. 

Perhaps the earliest symptom of fever is that general sense of 
lassitude and discomfort known as malaise; but if the patient be 
examined by the physician at this time, it will be found that there 
is already a slight rise of temperature and an increase in the rapid- 
ity of the pulse. The skin of the head and the body feels warmer 
to the touch, although the extremities may be cold. If the febrile 
attack is severe and the temperature is rising rapidly, this condi- 
tion will quickly be followed by the group of symptoms known as 
the chill. These symptoms are a sense of cold, with coolness of 
the skin, particularly the extremities ; paleness and sometimes 
cyanosis of the face, accompanied with involuntary movements 
of trembling and chattering. The duration of this period may 
be one or two hours, and will be followed by a sensation of 
undue warmth. The face will be found flushed, and the sur- 
face of the body will be considerably warmer to the touch. The 
patient, who at first crouches over the fife or covers himself 



::-5 5 VRGICAL PATHOLOGY AND THERAPEUTICS. 

with many blankets, now seeks relief by removing the clothing. 
If the rise of temperature — or the stage of invasion, as it is called — 

is mz:i :::-.'. the mili is rsrmly zbser: The 5 1 : i; ;. srme ::" fever. 
:: -v\:.. . is mm rzrirr. vxrith the temremmre remzirs i: its 
highest point. This stage may be reached in a few hours, or it may 
be several days before the period of invasion has been completed. 

The semrz stmze is r:zrz::er:ze i : hem mm zryress :f the skin. 
by dryness of the tongue, by thirst, by scanty urine, and by head- 

mhe — izh mme rims zlisrzrbmme :f the rermrs system :":".". :~ ez 
by the period of defervescence^ during which the skin becomes 
rrrls: z: times mme is rmfzse rersrirztizr zmz the mmzerzrzre 
rerzrrs :■: mrrml Tzmirv ::mmles:er:e mere zre irremtmriries 
ir me termerzr :re — hi:h rrzy be slirhtly rmisez ir : he everirr. :: 
rmy :':: z my :: : - : mm be". :~ the r :rmm z mzr the temr-ermrre 
heir,: i mmy mmmlesterte s rsrez title t: slirm: irri:z:i:r.s Ir: fzzm 
mses there rmy be z rzzm fm". :f :emz«erzrzre. even be'.:™ the r:z- 
mal, or in the moribund period there may be an excessive rise, 
---'.v.:'. : ~iii ever zzrrirre f:r r- sh:rt rime mter fez::: Tire tem- 
yr:.;:: -.varies ir mm mrzls : ir milzrer mere me rrez: fmrres 
zmz i: frezyzertly rzrs him: ir :iz petrle me rise :f temr-ermrre 
is r :: s: rrezt Z m mr me ztmzk the tzztier: mii hzve its: m:i::. 
the ermrizzim — iii be m:re :r less mrrker m:::v: :: me 
mmrm :: me rever. 

The mm: termerrtrre is zs ~mi ':e seer yzsry remzrzez rs me 
yizmz symr::m :f fever, rs :: is m:re mzsmz: mm zzy ::her 
syrrrtztr There zre zzmiztemy zrses ir -v'mizh me temrerzmre 
:s temporarily -; :she: zz zb:ve zz z:zzh by .: zerriem e.imirz- 
ri:r : :' hem zs ir exmerhmerzs :: —him zztertim hrs zirezzybeer 
zmie: —him mrrz: be rermzez zs fever zrz :he:e zre ms: 



i:ss :f her: m :: :'z:zi zzzzzz:z the remremrme mm fm". 
be".:— me r: rzr.il r-:ir: zrrhm me rrzrress :f zhsezse bz: these 
mrzmms zre exzerti.mzl There zre zis: s:me :zses :f excessive 
:: term-miry rise ir remr-ermrre ::: rervzrs ziseises "him. by 
szme. zre m: remzrzez rs febrile ir rzvzre. 

K:~ :her shili the rise :f temr-ermrre m zm.zmez f:r- Ore 
■:z the eirlies: zttemrts :: exrizir mis rise t^s rmze by Trzzbe 
~h: mr z ri:reer ir :he mm : f the temz-erzvzrz ir fever. His 
:he:r- -z-s :: — z zvzzzzz: izvz'zrz ^zzz: he szrr-:sez. 
zzzsez z ::rtrz:ti:r : f the zrterizies m the szrfzm ::' the b:-fv 
rimirishixr rreztiy the hem-elimirmi:r 7mer the ryr> 
:zz: mztenz. m mv t: rs zm zz: :::: the sersiti*. eress : the 



FE I r ER. 309 

vaso-motor system, makes an unusually intense impression, a rapid 
rise of temperature follows : in this case there would be a great dif- 
ference in temperature between the central and peripheral portions 
of the nerves, and a chill would be the result. The fall of the 
temperature would be caused by a relaxation of the vessels and a 
consequent increase in heat-dissipation. According to this theory, 
no increased production of heat takes place. Since then it has, 
however, repeatedly been shown that there is not only an increased 
production of heat, but there is also an increased elimination. The 
warmth perceived by the hand or by more accurate thermometrical 
tests shows that more heat is given off than is usual. If in the 
mean time the temperature remains the same or increases, more 
heat must necessarily have been produced. The actual amount of 
heat produced can be determined by calorimetric test, the amount 
of heat-dissipation within a given time being thus determined, and 
the heat-production calculated after allowing for certain changes 
of temperature occurring during the experiment. It may, how- 
ever, be determined by observing the oxidation process, as will be 
seen presently. 

There was at first much opposition to Traube's view, but later 
there has been a disposition to accept the theory of a diminished 
loss of heat as an important factor in the production of fever. 
Rosenthal has recently shown that in experiments upon animals 
heat-loss is diminished and heat-production is not increased in 
fever; Maragliano found that antipyretics act by causing a dilata- 
tion of the superficial vessels, and that when the action of the drugs 
ceases and the fever returns this relapse is preceded by a new con- 
striction of the vessels ; Walton has shown by experiment that the 
symptoms of fever can be produced by a primary shutting in of 
heat, but he accepts, nevertheless, the view of increased heat-pro- 
duction in fever. 

During the chill it may be assumed that there is a greatly- 
increased amount of heat produced, while the loss of heat is 
diminished, owing to the contraction of the vessels of the skin. 
By this contraction the heat-supply is also prevented from reaching 
the terminal branches of the nerves in the skin, which is the ther- 
mic apparatus by which heat or cold is perceived. According to 
Cohnheim, the variations of temperature are perceived by the 
warming or the cooling of this apparatus, and, owing to the 
cooling of these nerves, the sensation of chilliness is thus pro- 
duced. As the heat-loss is diminished, heat must consequently 
be heaped up in the interior of the body, and the temperature 



310 SURGICAL PATHOLOGY AND THERAPEUTICS. 

must rise rapidly. A change of several degrees within an hour is 
a not uncommon occurrence under these circumstances. 

Individuals whose regulating apparatus is easily disturbed are 
subject to slight chills from various causes. Excessive muscular 
action, as in mountain-climbing, may increase the heat-production 
three- or four-fold, and if the heat-elimination is not sufficiently 
active or if it is too suddenly arrested, a rise of temperature with 
chill may result. Such a disturbance may prove to be temporary 
only, but serious congestion may be caused in this way. 

By the time the second stage of fever is reached it will be found 
that the temperature has ceased to rise; that the regulating process 
is not entirely suspended; that the spasm in the superficial vessels 
passes off; and that there is a free flow of blood through them. In 
this way the active elimination of heat is re-established. Some 
authorities look upon heat as an excretory product, like urea. 
Maclagan says: "Increased formation of any excretory product 
leads to a stimulation and increased activity of the organ by 
which it is eliminated;" consequently the increased heat-dissipa- 
tion soon balances the increased heat-production, and no further 
rise of temperature takes place. A more careful observation of a 
patient at this time will show that there are great irregularities in 
the heat-dissipation, the surface temperature changing from hour to 
hour, but on the whole the amount of heat lost is much greater 
than that produced. It will also be found that the heat-production 
varies somewhat at this stage. The height of the temperature is, 
consequently, the result of the balance between the two. 

Heat-production must not be confused with high temperature. 
The temperature may be high with a moderate production of heat 
only, owing to diminished loss of heat, and it may be low when the 
production is high, owing to an excessive elimination of heat. 

It may be surprising to learn that the amount of heat produced 
in fever is really not much greater than that produced by a strong 
healthy man on full diet: it is, however, much greater than that 
produced by a well man on fever diet and at rest; but the chief 
point of difference in the heat- production of the sick and of the 
well man is, that in the latter the extra heat-production is limited 
to periods of active exercise or following hearty meals, whereas in 
the sick man the increased production is going on continually. 
The heat-elimination in fever is most active when the heat-pro- 
duction is least; that is, during the early stages and height of the 
fever it is irregular in its action, whereas in health the increased 
amount of heat produced at any time is rapidly disposed of by free 



FEVER. 311 

perspiration; the insensible perspiration is also more abundant and 
constant than in fever. The two factors of heat-regnlation are, 
therefore, acting more or less independently of one another in 
fever. 

Coming now to the stages of defervescence, it is seen that the 
temperature is beginning to fall: this appears to be due chiefly to 
the fact that the production of heat is now less active. The elim- 
ination of heat is, however, greater than at any other period of the 
fever. Whether the perspiration seen at this time is due to the 
flooding of the cutaneous vessels with warm blood or to an irri- 
tation of nerves presiding over this secretion is not satisfactorily 
determined. 

Under certain circumstances the temperature runs to an unu- 
sual height, and the condition is then known as hyperpyrexia, the 
temperature ranging from 108 F. to no° F. This condition is 
explained in different ways : by some it is supposed to be caused 
by imperfect elimination of heat, which function has become so 
profoundly disturbed that the heat-production cannot stimulate it 
into action. 

The question now naturally arises, What is the cause of the 
increased heat-production in fever? It was supposed at one time 
that local inflammation — of a wound, for instance — was the source 
of heat-production. The amount is, however, far too little to pro- 
duce any material change of temperature. It has already been 
shown that the oxidation-processes are a source of heat in health, 
and it has long been known that the amount of carbonic acid 
exhaled from the lungs and of urea excreted by the kidneys is 
greatly increased in fever. Experiments on fever patients have 
shown that the amount of carbonic acid eliminated may be 
increased from 70 to 80 per cent., and that during the chill two 
and a half times the normal amount may be given off. It is only 
quite recently that it has been definitely determined that there is 
an increased absorption of oxygen going on at the same time. 
Elaborate observations by Lilienfeld showed that both of these 
gases were proportionately increased in fever — that the change 
was not qualitative, but quantitative. He proved also that this 
increase is greatest with the rise of temperature, that the inter- 
change of these gases is somewhat less active at the height of the 
fever, and that during the defervescence it sinks somewhat below 
the normal. He further finds that the oxidation is not most active 
when the temperature is highest, but is most active before the latter 
is markedly raised and in the early stages of a rapid rise; moreover, 



312 SURGICAL PATHOLOGY AND THERAPEUTICS. 

that these processes go on just the same in fever if the temperature 
is kept down by some artificial means, such as a cold bath. He 
therefore concludes that the increased combustion in fever is not 
the result of increased temperature — that it can, indeed, take place 
independently of the latter — but that it is one of the factors which 
combine to cause the rise of temperature. There is also an in- 
creased amount of urea usually excreted before the rise of tem- 
perature begins, which is additional proof that metabolism precedes 
fever. 

L<ilienfeld further found that in the cases in which the temper- 
ature was kept down by the cold bath the oxidation-processes were 
more active. This corresponds with what has been observed in 
health when a man is placed in a cold bath, and is further proof 
that the regulation of the body-temperature continues in fever as 
in health, although not so accurately. 

It has already been shown that the heat-production of fever is 
not much greater than that of a man in health with active work, 
and the same is true of the amount of carbonic acid eliminated 
from the system. 

The increase in the amount of urea excreted, and other facts, 
point to the breaking down of albuminous products in fever. Pre- 
cisely how much these nitrogenous compounds contribute to the 
production of heat is not determined, but it is generally conceded 
that the increased production of heat is due to the active combus- 
tion taking place, and particularly to the oxidation-processes that 
have been described. The question which now remains to be set- 
tled is the seat of the oxidation-changes and the way in which they 
take place. 

It was originally supposed that the blood was the seat of these 
changes, and that fever consisted in an inflammation of the blood — 
a haemitis. The increased oxidation in the blood is, however, more 
apparent than in the normal state: some think the blood and abdom- 
inal viscera have, in fact, no appreciable participation in the metab- 
olism in fever. In many cases of fever evident changes take place 
in the blood, due to the action of pyrogenous material and micro- 
organisms. The breaking up of red corpuscles causes an increase 
of coloring matter in the urine; the chemical examination of the 
blood in fever has not yet produced any important results. In some 
fevers are found the buffy coat and a delay in the coagulation; under 
some circumstances a great diminution of the fibriu, particularly in 
animals after the injection of putrefactive substances; also a diminu- 
tion of the red corpuscles and an increase of the white corpuscles, 



FEVER. 313 

or, again, the white corpuscles may be greatly diminished, in which 
case there is a great increase of the fibrin element, which so raises 
the coagulability that dangerous capillary thrombosis may take 
place. It is probable that the elements which disappear from the 
blood are destroyed there by combustion, which is the result of the 
fermentative changes going on in the blood, and consequently that 
the blood also is a source of heat. The amount of heat, however, 
produced by the blood and the glandular tissue is probably small. 

It has already been seen that in health the muscles are the chief 
sources of heat. Thermo-electric experiments show that in fever 
in animals the temperature of the non-contracted muscles as well 
as of the iliac vein is higher than the arterial blood coming from 
the left heart, while in the normal animal it is lower. It is evident, 
therefore, that heat-production in fever is increased in the muscular 
tissue even when at rest. 

These and other experiments justify the assumption that the 
innervation of the muscles is the cause of the increase of the 
oxidation-process in animals in fever, and, moreover, that it is 
through the nerves that the pyrogenous material produces the 
increased combustion in fever. H. C. Wood confirms this view, 
that fever is the result of a disturbance of the nervous system. As 
the result of his experiments he concludes that "there are nerve- 
centres which are directly concerned in the thermogenic function, 
and which affect the production of animal heat independently of 
the circulation by direct action upon the tissues." 

A word of explanation in regard to these nerve-centres, about 
which so much difference of opinion has existed, may be appro- 
priate here. 

Two kinds of nerves have been described — the excito-caloric 
nerves, which being irritated produce heat; and the inhibitory or 
moderating nerves, which restrain the action of the caloric nerves. 
As yet no definite information has been obtained as to the precise 
centre for heat-regulation, but it is known that a vaso-motor centre 
exists with its double set of nerves, and that the latter play an 
important part in the regulation of the body-temperature. 

If, now, there is an increased production of heat, there must 
be supposed an increased action of the excito-caloric or the " cata- 
bolic " nerves, with increased oxidation and a diminished action of 
the inhibitory or the "moderating" or the "anabolic" nerves, 
with diminution of the constructive or building-up processes. If 
this increased action of the heat-producing nerves continues, the 
vaso-motor mechanism is next called into action, and for a time it 



314 SURGICAL PATHOLOGY AND THERAPEUTICS. 

may be able to regulate the temperature. This apparatus eventually 
becomes unequal to the task, and a rise of temperature is the result, 
or from the outset its action may be so altered, owing to the disturb- 
ance of the heat-regulating centre, that the vessels contract and the 
rise of temperature takes place more rapidly. If the heat-eliminat- 
ing function is profoundly disturbed at any time — that is, if the 
inhibitory nerves are paralyzed and the vaso-motor nerves are 
unable to dispose of the accumulated heat — there will be an 
unusually high temperature, or hyperpyrexia. This is the neur- 
otic theory of fever. It must not be forgotten, however, that many 
still think that the combustion theory — that is, that increased heat- 
production may take place by increased oxidation of the tissues 
independently of the nerves — is sufficient to account for most cases 
of fever; but this view hardly seems in accord with the latest and 
most reliable investigation. 

Having discussed the nature of fever, it will be proper to give a 
few moments' consideration to its cause. It will not seem surpris- 
ing, therefore, from what has been said, that fevers of purely ner- 
vous origin may occur, as, for instance, febrile attacks following 
fright or in the course of purely nervous disease. Urethral fever 
has already been cited as an example of fever occasionally pro- 
duced by reflex irritation of the nervous system. 

In the large majority of cases, fever, particularly the surgical 
form, is due to the presence of some foreign substance in the 
blood. The pioneers in investigating these substances were Bill- 
roth and Weber, whose injections of pus and putrefactive materials 
into the blood of animals were followed by marked febrile disturb- 
ance. They also injected purely chemical substances which were 
supposed to be agents in the putrefactive process, such as butyric 
acid, leucin, and ammonia salts, with similar results. It was found, 
further, that very small doses produced the same result, whereas 
large doses of such substances as sulphide of ammonium, carbonate 
of ammonia, and butyric acid depressed the temperature. The 
severity of the fever appeared to depend upon the quality of the 
virus rather than its quantity. Fresh pus and pus-serum and dried 
pus have all been found to be pyrogenous, but pus stagnating for a 
long time in the body, like that found in cold abscesses, does not 
possess this quality. It was finally discovered that the active prop- 
erties of this class of pyrogenous substances were due to the pres- 
ence of bacteria. Exactly how bacteria cause the febrile irritation, 
whether by the chemical changes they bring about in the blood 
during their development, or whether by their simple presence 



FEVER. 315 

there, has not fully been determined. It is known that many 
surgical fevers are due to the presence of a chemical substance, a 
ptomaine, in the blood and tissues absorbed from wounds when 
putrefactive changes are taking place due to the presence of 
bacteria. 

Genuine fever may, however, take place without the action of 
bacteria. Febrile disturbance may occur in cases where perfect 
asepsis has been preserved and the wound is healing by first inten- 
tion. Subcutaneous injuries, such as simple fractures, contusions 
of joints or of the soft tissues, are often followed by fever. Transfu- 
sion of blood, of hydrocele fluid, and even of pure water, was found 
to be followed by fever. In the breaking down of the protoplasm of 
cells there are liberated ferment substances that are similar to those 
described as fibrin-ferment, a substance found in the blood. In 
blood removed from the body this ferment substance is liberated, 
and the injection of this blood into the circulation of an animal 
may cause extensive and even rapidly fatal thrombosis. Weak 
solutions of this ferment substance when injected will cause a rise 
of temperature. Other ferments, such as pepsin and pancreatin, 
have been injected into the blood and have caused fever. The 
milder forms of fever, such as occur in aseptic wounds, simple 
fractures, and subcutaneous injuries, are produced by ferment-like 
substances which differ slightly from those produced physiologi- 
cally. Substances which, chemically, differ greatly from the chem- 
ical combinations found in the fluids and tissues of the body, as the 
ptomaines, produce when absorbed severe forms of fever. Bacteria 
are found in the blood and the tissues of the body in the severer 
forms of traumatic infective disease, hi general it may be said, 
therefore, that fever is due to the presence in the blood of a pyrog- 
enous substance of an organic nature that may have been produced 
by bacteria; or to the presence of bacteria ; or, finally, to some fer- 
ment-like substance which has resulted from cell-disintegration. 

The question has been raised whether the increased temperature 
in fever is the result of an effort on the part of the body to protect 
itself against invading organisms — whether, in other words, it is the 
result of a struggle for existence between the body and the bac- 
teria. It has been argued that such a widespread condition com- 
mon to man and all warm-blooded animals would not otherwise 
exist. It would need much more light than we now have to deter- 
mine whether this is the case, or whether the organism has so far 
gained the victory that it has been able to bring about such reac- 
tions as are favorable for its well-being. (See Hankin, p. 153.) 



XIII. SURGICAL FEVERS. 

The reader is now prepared to study the different types of fever 
that may occur during the healing process. 

Traumatic Fever, — In old times, before the days of antiseptic 
surgery, no wound was supposed to heal without considerable con- 
stitutional disturbance. It was indeed thought essential that a brisk 
inflammatory reaction should follow an operation in order that the 
process of repair should effectually be carried out. After an am- 
putation of the thigh, for instance, the water-dressings were re- 
moved on the second day, and a considerable discharge would be 
liberated and now either through the drainage-tubes or from open- 
ings through which protruded the long ends of ligatures that were 
always left uncut. On the third day the sero-sanguinolent dis- 
charge would be found mingled with pus, and the amount of 
swelling and redness of the parts had by this time become so great 
that many of the stitches were cut and the water-dressings were 
exchanged for poultices. Free suppuration was followed by the 
discharge of sloughs of connective tissue, of ligatures, of frag- 
ments of decomposed blood-clots, and finally by a subsidence of the 
severer symptoms of inflammation, and the wound then began 
slowly to heal by granulation. So frequent of occurrence was this 
traumatic inflammation that many surgeons, particularly the 
French, preferred to leave the wounds entirely open, and they 
stuffed them with charpie, so that healing by first intention could 
not take place in any part of the wound, and the discharges, 
which were regarded as an almost inevitable result of operations, 
could have free vent. It is not surprising that with this local 
inflammation there should have been also considerable constitu- 
tional disturbance. To this condition was given the name trau- 
matic or surgical feve)\ which was regarded almost as much a 
physiological as a pathological process, and as an essential element 
in repair — a healthy reaction, as it were, in its early stages at least, 
from the shock of the operation. 

Let the symptoms of this type of fever be traced through the 
week following a capital operation. On the afternoon and evening 
of the day on which the operation has been performed no symp- 
toms are seen that indicate the approach of febrile disturbance; on 

316 



SURGICAL FEVERS. 317 

the contrary, there is an unusual pallor in the complexion, the 
skin is cold, the pulse is weak, and at times is easily made to dis- 
appear altogether by firm pressure of the fingers upon the wrist. 
The patient lies motionless in bed and groans feebly at inter- 
vals. The respirations are somewhat superficial, and there may 
be some nausea or vomiting continuing beyond the period of 
excitement which follows anaesthesia. If at this time the ther- 
mometer be placed in the mouth, in the axilla, or even in the rec- 
tum, it will be found that the record is below the normal line. 
This is a condition known as " shock," of which more will be said 
in a subsequent chapter, and a very anxious period it is to the 
surgeon. 

By the following morning, owing perhaps to the liberal use of 
stimulants, to heat, and to good nursing, the pulse has become 
stronger, perhaps even stronger than usual, and often is less rapid 
than the night before; the skin is hot and dry and the cheeks are 
flushed. The patient has rallied well from the shock of the opera- 
tion, and reaction is said to have been established. In truth, this 
condition should not be called reaction, it simply being a return 
from the condition of the night before to a purely normal state. 
Science has been able to show that what is now under observation 
is something more than the swing of the pendulum, and that, on 
the contrary, there is another and entirely new pathological con- 
dition to deal with. If the thermometer be placed in the axilla, 
there will be found a record of high temperature, ioo° to 102 ° F., 
or even higher 1 . On the evening of this the second day all these 
symptoms will be more pronounced, and in addition there will be 
found a coated tongue, thirst, considerable restlessness, and a gen- 
eral sense of malaise, and the chances are that both on account of 
these symptoms and of the pain of the wound the patient will be 
unable to sleep. On the following morning the temperature will 
drop a degree, to rise only higher than before on the evening of the 
third day. By this time some delirium may have been noticed by 
the nurse. An examination of the wound on the following morn- 
ing will show the establishment of suppuration, and as the wound 
is cleaned off by a free flow of pus the temperature will begin to 
drop, and by the fourth day, for the first time, a marked fall in the 
temperature will be found, accompanied by a disappearance of 
many of the uncomfortable symptoms of fever (Fig. 65). If the 

1 In taking temperature the clinical thermometer may be left three minutes in the mouth 
or from five to ten minutes in the axilla. In rare cases, as in severe shock, the exact temper- 
ature of the body can be determined by placing the thermometer in the rectum. 



3i8 



SURGICAL PATHOLOGY AND THERAPEUTICS. 



suppuration be abundant, there will be an evening rise of tempera- 
ture for a few days longer. This type of fever, preceding usually 



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suppuration in the wound, lasts from one to two weeks accord- 
ing to the severity of the case. 

The relation of the pyogenic bacteria to inflammation and sup- 
puration has already been discussed in a previous chapter. What 
is of interest here is simply to determine what part bacteria play in 
the general disturbance of the system, or, in other words, what is 
the pyrogenous or fever-producing substance. 

Bacteria are frequently found in the blood during surgical fever 
— at times the pyogenic cocci, at times other forms. It depends 
somewhat upon the condition of the system whether they become 
more numerous or are destroyed by the blood-serum and elimi- 
nated through the excretory organs. They are not present in suf- 
ficient numbers or with sufficient regularity to be regarded as the 
cause of fever. They are, on the one hand, rather an indication 
of the depressed vitality of the system, which enables them to 
obtain an entrance into the circulation. On the other hand, the 
pyrogenous action of chemical substances has fully been recog- 
nized. Further observations have not succeeded, however, in nar- 
rowing down the fever-producing qualities to any one chemical 
substance. On the contrary, it is probable, during the process of 
decomposition which is taking place in the blood, lymph, and in 
fragments of tissue in the wound, that quite a number of chemical 
substances are liberated and absorbed into the system. The sub- 
stances that cause surgical fever are therefore varied in their 
nature. 

When suppuration is established and the wound "cleans off," 



SURGICAL FEVERS. 319 

these ptomaines are washed away in the fragments which come 
from the wound, and the fever immediately subsides. Had the 
fever been due entirely to bacteria, such a change in the wound 
would not have produced so immediate an effect upon the system. 
Such organisms as are still in the circulation are eliminated 
quickly as soon as the system rallies from the depressing influence 
of ptomaine action. 

Indeed, in surgical fever the constitutional disturbance corre- 
sponds pretty accurately with the severity of the local inflammation 
and with the amount and quality of the secretions of the wound. 
A sharp rise of temperature, accompanied by delirium, by diges- 
tive disturbances, and by other signs of constitutional irritation, 
would almost certainly indicate the presence of decomposition in 
the retained fluids, the formation of an abscess, or the development 
of some form of infective inflammation. 

Aseptic Fever. — When the antiseptic treatment was introduced 
it was expected that wounds healing by first intention, and conse- 
quently devoid of septic contamination, would unite without any 
febrile disturbance. In aseptic wounds the signs of inflammation 
are almost completely absent: there is but slight swelling; the sur- 
face of the wound is natural in color; the serum flows away almost 
in the condition in which it escaped from the vessels, slightly tur- 
bid, mixed with white corpuscles or tinged with red, and devoid 
of odor. It is mild and unirritating in character. 

It would be natural to suppose that under these circumstances 
there would be a corresponding absence of all reaction upon the 
system. It was found, however, that a considerable rise of tem- 
perature took place after aseptic operations, without any local 
changes sufficient to account for this rise. It is true that occa- 
sionally, in properly-conducted operations, great tension of the 
stitches, imperfect drainage, sloughing of the flaps, or some irrita- 
tion arising from the dressings was found, but more frequently 
no imperfections of this kind were discoverable. 

A more careful observation of the symptoms of this form of 
fever showed that many of the peculiarities of surgical fever were 
wanting, and, in fact, that there arose a new type of fever — the 
aseptic fever. 

The action of the virus upon the nerve-centres — which action is 
so characteristic of surgical fever, such as delirium, insomnia, pros- 
tration, and disturbance of digestion — is here wanting. In fact, 
from the appearance merely of the patient it is improbable that the 
presence of fever would be recognized. Such patients sleep well, 



320 



SURGICAL PATHOLOGY AND THERAPEUTICS. 



can sit up in bed, and are interested in what is going on about 
them, or can even walk about without fatigue or other bad results. 
Except the rise of temperature recorded by the thermometer there 
is no symptom of constitutional disturbance. 

It is, therefore, not surprising that many subcutaneous injuries 
which were supposed to produce no general impression upon the 
system are now found to be accompanied by a rise of temperature 
of several days' duration, and until it occurred to some one to 
take thermometric observations on this class of cases no symptom 
of fever, as ordinarily seen, was observed. In cases that have been 
operated upon there may be coating of the tongue and gastric dis- 
turbance due to the anaesthesia. The skin, however, is not so hot 
as in other forms of fever, and it may be moist; the urine is not 
diminished, and there is less loss of weight than in septic fever. 
The rapidity of the pulse corresponds pretty closely to the rise of 
temperature. 

This fever, although harmless and without any special signif- 
icance, may last from one to two weeks. Ordinarily, however, the 
temperature returns to normal at the end of three or four days. 



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66. — Aseptic Fever due to the Absorption of Blood-clot. 



Two examples, taken from the writer's note-book of several 
years ago, will serve to give types of this form of fever: 

i. Miss L was operated upon (in 1889) for a tumor of the right breast. 

The breast and the axillary tissues were dissected out. A deep axillary 
stitch and a deep breast-stitch were taken, and two bone drainage-tubes 
inserted, one near each suture. The dressings were removed the same even- 
ing, owing to a hemorrhage from the axillary tube caused apparently by the 
tearing out of the axillary stitch. A new dressing was applied, and was left 
untouched for several days. On its removal it was found that the wound had 



SURGICAL FEVERS. 321 

healed by first intention and that the drainage-tubes had been absorbed. 
Nevertheless, the temperature did not reach the normal line until the 
eleventh day. The pulse kept pretty accurate pace with the temperature 
(Fig. 66). 

2. In contrast with the above case ma}' be mentioned that of Mrs. R , 

whose breast and axilla underwent a much more extensive dissection. Here 
the stitches all held well and the walls were kept firmly in apposition, the 
tubes discharging the exudation which took place. The temperature rose to 
99. 5 F. on the evening of the second day, but with this exception it was 
normal from the beginning to the end of convalescence, which was rapid. 

It is evident from a study of these cases that there was no absorp- 
tion of septic materials or of inflammatory products, for inflammation 
was either absent or was present in such a mild form that it could 
not be regarded as belonging to the infective type. In those cases 
in which the temperature has been above normal there has doubt- 
less been an absorption of certain materials which accumulated 
between the surfaces of the wound or at the seat of injury. These 
materials are blood-clot, serous exudations which failed to escape 
through the drainage-tubes, fragments of broken-down tissue, and 
minute sloughs, which, if observed under the microscope, are found 
to be undergoing a granular disintegration preparatory to absorp- 
tion. 

In a section taken from a wound in the abdominal wall the 
wound was found to have united, but beneath the surface of one 
of the lips was seen a granular mass of material which represented 
a dead portion of the skin about to be absorbed. Such changes 
are seen on a larger scale in very extensive wounds, such as ampu- 
tation at the hip-joint, or in crushed wounds which have been 
thoroughly disinfected and are healing well. In both these cases 
the amount of disintegration with injury in the cellular tissue, the 
integuments, and even the muscles, must be considerable. Let us 
see what the effect of the introduction of such substances into the 
circulation has been shown to be by experiment. 

The chemistry of coagulation has already been alluded to, and 
the reader is aware of the process by which fibrin is formed. 
Occasionally small quantities of fibrin-ferment are liberated in the 
circulating blood by the breaking down of cells, but the vessels 
appear able to dispose of it and to prevent any coagulating action. 
When, however, this ferment is introduced into the circulation in 
any considerable quantity, remarkable results are found from its 
action. The fluid part of coagulated blood, if introduced into the 
circulation of an animal, will bring about a very pronounced and 
extensive coagulation. 
21 



322 SURGICAL PATHOLOGY AND THERAPEUTICS. 

From 10 to 12 cc. of blood are taken from a rabbit and allowed to coagu- 
late into a solid cake : the fluid being pressed out and filtered, 5 to 6 cc. are 
then carefully injected into the jugular vein of the same animal. Immediately 
there occur opisthotonos, dilatation of the pupils, dyspnoea, etc., the symp- 
toms of fatal pulmonary embolism. On examination the right heart is found 
full of tough clot, although still beating, and the ramifications of the pul- 
monary artery are distended with a red thrombus. The left heart has small- 
sized clots, but the blood in the remaining vessels is strikingly hard and 
slow to coagulate. Solutions of blood-corpuscles in ether and solution of 
haemoglobin have also produced similar results. Other observers have also 
recorded a rise of temperature from the injection of defibrinated blood. 

The same group of symptoms was also produced by watery 
extracts of pulverized blood freed from its ferment, which was 
accounted for by assuming that ferment was developed in the 
blood. The rise of temperature produced by the injection of water 
was explained in the same way. Solutions of carbolic acid were 
found at times to weaken, and at times to increase, the action of 
the ferment, particularly when strong. 

Indeed, quite a variety of substances of ferment-like nature, 
such as pepsin and pancreatin, are pyrogenic in their action quite 
independently of any bacterial infection. The breaking down and 
absorption of the blood-clot or coagulated serum caught between 
the apposed surfaces of a wound or surrounding the ends of a frac- 
tured bone, or in a large hsematoma, must therefore necessarily 
liberate pyrogenous substances which are readily absorbed. The 
same may be said of other cell-structures, as connective tissue or 
muscle. With the disintegration of bruised masses of tissue like 
these, either as' the result of direct injury or from the cutting off 
of the circulation, there is liberated not only fibrin-ferment, but 
doubtless also other substances slightly altered from their original 
composition during life, which substances, when absorbed, produce 
a rise of temperature. Their close relationship to living substances 
renders them less intolerant to the system than the more virulent 
substances manufactured by bacterial action; consequently we fail 
to observe many of the more disagreeable symptoms of fever. 
These homologous substances appear to have the power to act upon 
the thermic centres, but to cause little other disturbance in the 
economy. 

When a large wound heals with a minimum amount of fever, as 
in the amputation of the breast above alluded to, the adjustment 
of the wound has been so perfect that no blood-clot forms between 
its lips: the incisions have been cleanly cut with the knife, and 
no fragments remain behind to be absorbed. The effusion of 



SURGICAL FEVERS. 323 

serum that always occurs in greater or lesser quantity is either 
checked by the firm pressure of the dressings or is conducted off 
immediately through the drainage-tubes. Many compound frac- 
tures which have been thoroughly cleaned of clot and properly 
drained heal without rise of temperature, while a simple fracture 
may show a fever-curve of several days' duration. 

There are, however, many slight disturbances which, occurring 
during the healing process of a wound dressed with aseptic precau- 
tions, cause a rise of temperature, and which should not be over- 
looked. Great tension of the lips of the wound may cause ulcera- 
tion about the stitch-holes. Minute quantities of micrococci may 
be found in the secretions accumulating at such spots. The micro- 
cocci are insufficient in numbers, or they are so enfeebled by the 
antiseptics with which they come in contact as to have the power 
to cause putrefactive action, but they may be able to liberate a fer- 
ment capable of producing a rise of temperature. Collections of 
fluid may be caused by imperfect drainage, which collections, 
although aseptic, are still pyrogenous. 

Finally, it must not be forgotten that the powerful antiseptic 
agents employed are potent for evil as well as for good. The 
poisonous action of carbolic acid and of iodoform is now well rec- 
ognized, but undoubtedly many a fatal case of poisoning by these 
agents has been mistaken for septic infection. The rise of tem- 
perature and the digestive disturbance, with the presence of pro- 
nounced nervous symptoms, produced by carbolic-acid absorption 
caused the writer to be summoned in haste to a supposed case of 
blood-poisoning. The dark color of the urine gave at once a clue 
to the diagnosis. Delirium accompanying an unusual amount of 
inflammation after an operation for rectocele induced the writer on 
one occasion to take out the stitches so early as to lose much of the 
benefit which might have been derived from a successful operation. 
The cause of the trouble was subsequently found to be due to the 
excessive use of iodoform powder by an over-zealous nurse. 

Surgical Scarlet Fever. — Many drugs. are apt to cause eruptions 
which, in some cases, resemble those of scarlet fever. This disease 
has, in fact, been associated closely with surgical operations, and 
this supposed connection has given rise to the expression "surgical 
scarlet fever." Observations of this kind are exceedingly numer- 
ous, and few surgeons have failed to meet with them ; whereas the 
association of other exanthemata — as, for instance, measles — with 
surgical operations does not appear to occur in sufficient numbers 
to be worthy of special notice. 



324 SURGICAL PATHOLOGY AND THERAPEUTICS. 

Horsley refers to the fact that scarlet fever is particularly liable 
to attack children recently operated upon, especially in cases where 
an operation has been performed for stone in the bladder or for 
cleft palate. Sir James Paget, who is one of the chief authorities 
on this subject, is confident that there is something in the conse- 
quences of surgical operations that makes patients peculiarly sus- 
ceptible to the influence of the scarlatina poison. He mentions 
the following case: 

A boy operated upon for stone had an eruption with fever exactly like 
that of scarlet fever the day following the operation. Two days later it 
began to fade, and quickly disappeared. A month later, when the wound had 
nearly healed, he had hsematuria and increased mucus, with pain on micturi- 
tion: Two days after this he had sore throat, accompanied with a scarlatina 
eruption, followed by desquamation. 

Although the symptoms, in this case, of two attacks were not 
typical, Paget regards it as true scarlet fever. Thomas Smith had 
10 cases of scarlet fever in 43 cases of lithotomy in children. 
This is certainly more than a coincidence. In all cases the erup- 
tion appeared on the second or third day. 

The appearance of scarlet fever in puerperal women is a well- 
recognized occurrence, and all the symptoms are usually so well 
marked that little doubt is expressed about the diagnosis. The 
somewhat ' ' disorderly ' ' appearance of the symptoms in surgical 
cases, as Sir James Paget expresses it, has led to the belief that 
these cases are not genuine scarlatina, but of septic infection of the 
wound; and the fact that eruptions of this character are often seen 
in the course of pyaemia appears to be confirmatory of this view. 
In a monograph on this subject Albert Hoffa states that he analyzed 
the different forms of eruptions which occur during the healing of 
a wound, and recognized four types. A certain number he regards 
as purely vaso-motor disturbances, arising from an irritation of the 
sensitive nerves and occurring after operations upon parts abun- 
dantly supplied with nerves, such as the genitalia. The eruption 
appears a few hours after an operation for circumcision, for 
instance, and resembles an erythema or an urticaria, and disap- 
pears as quickly. The cases of puerperal scarlet fever are also 
placed in this category by Hoffa. 

The next class he calls ' c toxic erythema. ' ' These eruptions are 
analogous to the medicinal eruptions (as the rash which sometimes 
follows the use of copaiba or antipyrine). They occur without pro- 
dromal symptoms, and usually appear from twenty-four to forty- 
eight hours after all kinds of operations, and even in simple frac- 



SURGICAL FEVERS. 325 

tures. The febrile disturbance is usually intense, and in children 
delirium or coma may accompany the eruptions. Gastric disturb- 
ance is also a prominent symptom. Toxic erythema appears as a 
diffused redness or as isolated large patches with comparatively 
clear intervals between them. It is seen only on the body and 
extremities, and disappears in twenty-four hours without any sub- 
sequent desquamation. 

This form is the result of an absorption of the secretions of the 
wound — particles of tissue or fibrin-ferment — such as occurs in 
aseptic fever. In some of the experiments of transfusion in ani- 
mals patches of eruption are noticed. It is a not uncommon occur- 
rence to find transitory erythema during etherization. The erup- 
tions of carbolic-acid and sublimate poisonings would belong in 
this category. Hoffa reports the case of a boy whose resected 
knee-joint wound was syringed out with a 1 : 1000 solution of subli- 
mate. Half an hour later the patient had a chill accompanied with 
fever and typical scarlet rash on the whole body that lasted for 
twenty-four hours. The presence of mercury was afterward dem- 
onstrated in the urine and faeces. 

These two varieties are strictly to be distinguished from the third 
form, which is infectious, and in which the eruptions are indications 
of a general infection of the body, occurring as they do in septicaemia 
and pyaemia. The eruptions are generally more marked in charac- 
ter and exhibit a greater variety in appearance. They may appear 
in the form of erythema or as urticaria. They may be diffused or 
be in isolated patches. The eruption may become pustular or hem- 
orrhagic. Even purpura spots may be seen. The eruption, how- 
ever, occasionally resembles the scarlet rash very closely. Some- 
times — curiously enough — it affects only one-half of the body. 
After disappearance of the eruption desquamation may follow, and 
there may even be suppuration beneath the skin, with the forma- 
tion of abscesses. The eruption is said to be caused by a capillary 
embolism of micrococci. An example of this type is reported by 
Ffolliott: 

A soldier in India received an extensive burn from the explosion of pow- 
der. On the third day a scarlet rash appeared. The temperature had been 
high from the beginning. In five days the eruption disappeared, and it was 
followed by desquamation. The patient had been three years in India, and 
in that country scarlet fever is never seen . 

Konetschke reports a case belonging to this variety: 

A boy with compound comminuted fracture of the leg had septic infection 
of the wound. In forty-eight hours after the injury an eruption appeared, 



326 SURGICAL PATHOLOGY AND THERAPEUTICS. 

with a rise of temperature, and remained six days, being followed by desqua- 
mation. Two weeks later a second eruption occurred, followed by desquama- 
tion, lasting only two days. One week later another eruption, with desqua- 
mation, lasting this time four days. There was some swelling of the legs 
each time, but no angina or swelling of the submaxillary gland, and no 
source of infection from scarlet fever was discernible. 

Finally, in another set of cases it is evident that we have to do 
with genuine scarlet fever; that is, there are, in addition to the 
skin eruption, angina, swelling of the submaxillary glands, desqua- 
mation, and nephritis. This regularity of symptoms is not consid- 
ered by Sir James Paget as necessary for diagnosis, for he expressly 
states that deviations from the typical course of scarlet fever are 
common, one or more symptoms being absent. 

Another point upon which a difference of opinion appears to 
exist is the origin of the attack. Hoffa is inclined to think that 
the disease enters the organism through the wound, and cites cases 
to show that the eruption often begins at the edges of the wound 
and gradually spreads over the body. Paget is inclined to the 
view that the patient may have imbibed the poison before the 
reception of the wound, and that the disease might not have 
shown itself at all unless the vitality of the system had been 
impaired. 

A case strongly suggestive of this view occurred in the writer's 
own practice: 

A little girl twelve years of age fell and cut her forehead against a sharp 
piece of furniture. The wound was cleansed and united by three sutures. 
That evening there was swelling of the edges of the wound and a rise of 
temperature. These symptoms were more marked the next morning, and 
on the following day a scarlet rash occurred, and the patient went through 
a typical case of scarlet fever. The wound healed by first intention. 

It seems quite evident, as Paget says, that u a peculiar liability 
to contagion is induced by an operation, and that the poison pro- 
duces its specific effects in much less than the usual period of incu- 
bation." It is also highly probable that direct infection through 
the wound occurs. Thus, Paget reports a case of a child who was 
seized with scarlet fever the day after an operation had been per- 
formed on her mouth. Her mother knew nothing of any source 
of poisonous infection, but the surgeon who performed the opera- 
tion was at the time nursing his own children with the disease. 
Billroth reports a similar case of scarlet fever following an opera- 
tion upon the tongue, and it seems probable at least that Smith's 
ten cases of scarlet fever following lithotomy may be examples of 
infection of a wounded mucous membrane by that disease. Hoffa 



SURGICAL FEVERS. 327 

thinks that the reason a wound seems to give a certain predisposi- 
tion for the disease is because a larger dose of the micro-organisms 
may enter through the wound, and that patients thus become 
affected who are not so affected by smaller numbers of bacteria 
through ordinary channels. The short incubation-period of surgi- 
cal scarlet fever favors this view. 

One of the most striking cases of infection of the wound by 
scarlet fever that the writer has been able to find is the following: 

A physician, apparently without predisposition to scarlatina, received a 
scratch with a knife at an autopsy of a case of scarlet fever. On the ninth 
day a rash started from the wound and followed a typical course. 

A case illustrating Hoffa's theory of wound-infection is the 
following: 

A patient with stricture and urinary infiltration and gangrene of the 
scrotum had, on the ninth da}* of entrance to the hospital, a scarlet rash 
starting from the wound and covering the abdomen, the breast, and the 
neck, to the lower third of the thighs, and remaining six days. Angina 
was present, also high fever. Two days after the disappearance of the rash 
desquamation took place. Death occurred on the eleventh day after the 
appearance of the rash. At the autopsy a parenchymatous nephritis was 
found. Four days after the appearance of the eruption on this patient, a boy 
in the same ward with a fractured thigh and lacerations in the perineum 
broke out with a rash on the limbs and face. It was followed by desquama- 
tion, but there was no angina, or albumin in the urine. 

It is probably not advisable to attempt to make a differential 
diagnosis from all kinds of skin eruptions or erythemata that may 
occur in surgical practice and scarlatina. Enough, however, has 
been said to show that a great many cases closely resemble that 
disease; that a certain number, and probably the majority, of cases 
of so-called ' ' surgical scarlet fever ' ' are cases of genuine scarla- 
tina; that some of the scarlet rashes that might easily be mistaken 
for the disease are cases of septic infection of the skin; that in 
many of these cases it is extremely difficult to decide between the 
two affections in making a diagnosis, and that it would be well to 
be on the safe side and exercise all the precautions necessary to iso- 
late the patient. 

Suppurative Fever. — The fevers thus far considered have not 
necessarily been directly connected with suppuration. In fact, it 
has been shown that surgical fever subsides with the appearance of 
pus. The fevers already mentioned are developed during the early 
stages of the healing process in wounds. They may, therefore, with 
propriety be called " primary fevers," although this name is not 
usually applied to them. The term secondary fever is, however, 



328 SURGICAL PATHOLOGY AND THERAPEUTICS. 

sometimes given to that form which occurs during the period of sup- 
puration, although suppurative fever is the more common expres- 
sion. Hectic fever (from eyrixoz, a habit) is a name usually applied to 
the chronic forms of suppuration, such as accompany tuberculosis. 

The high temperature usually accompanying aseptic or surgical 
fever rarely lasts beyond the first week. If, however, the temper- 
ature does not fall, or about the beginning of the second week there 
should be a sharp rise of temperature, or even a chill, then there is 
reason to suspect the presence of pus in the wound. If the wound 
be examined, undoubtedly there will be found an amount of inflam- 
mation which would account for the high temperature. The lips 
of the wound are red and swollen, and on removing an obstructed 
drainage-tube or on slightly separating the edges of the wound an 
escape of pus follows. If proper drainage and antiseptics are now 
employed, the temperature will soon fall and the febrile disturb- 
ances will disappear. If, however, parts are involved whose ana- 
tomical structure makes it difficult to effect a thorough disinfection 
of the wound (as, for instance, a joint), or pus begins to burrow 
among deep layers of muscles, as often happens in a compound 
fracture, the fever will continue to keep pace more or less accu- 
rately with the local condition. If the infective inflammation, 
which has now established itself, is of an acute type, there will 
be a continued form of fever with frequent marked exacerbations. 
Usually, however, the local inflammation yields more or less to 
proper remedies, and becomes less acute in character: numerous 
sinuses are formed running in various directions ; the integuments 
are swollen and oedematous, but are pale and flabby, and pus dis- 
charges freely from numerous openings. Chronic suppuration is 
established. The fever now assumes the characteristic remittent 
type of suppurative fever. In the morning the temperature is nor- 
mal or even subnormal, but in the afternoon there is a sharp rise, 
varying from two to six degrees. There are then the hectic flush 
and the other symptoms of fever. Unless the progress of the sup- 
puration is soon checked, the constitutional disturbance produces a 
marked change in the appearance of the patient. Great loss of 
flesh and prostration result, which are aggravated by "colliqua- 
tive" diarrhoea and by profuse perspiration or "night-sweats." 

Emaciation becomes extreme, so that the joints have an unusu- 
ally prominent appearance; bed-sores appear, and it soon becomes 
merely a question of the power of endurance on the part of the 
patient. In the most chronic forms of suppuration, such as accom- 
pany tubercular disease, this type of fever may continue for many 



SURGICAL FEVERS. 329 

months ; the emaciation will be more gradual, but when death 
finally occurs from exhaustion there will be found extensive 
amyloid disease of the internal organs. 

If in the early stages of the suppuration the surgeon gains con- 
trol by free incisions and drainage and removal of the suppurating 
walls of the wound by the curette, by resection of a joint, or by 
amputation, the febrile disturbance immediately subsides. This 
fact shows clearly that the high temperature is due to the contin- 
ued absorption of pyrogenous material from the wound into the 
blood, and that the material when once absorbed is no longer 
capable of further action, for when the supply is cut off pyrexia 
ceases. 

The precise nature of this poisonous substance is not fully 
understood. It is certain, however, that bacteria are only indi- 
rectly concerned in its production. The pus-coccus is indeed 
sometimes found in the blood, but it is also seen in cases where 
no febrile disturbance exists, and its presence is quite uncertain 
and irregular. The amount of degeneration of tissue and destruc- 
tion which such a process involves must necessarily liberate a 
number of pyrogenous materials which find their way into the 
circulation and produce fever. The extensive breaking down of 
white blood-corpuscles in the granulation tissue forming the wall 
of the abscess would alone liberate sufficient fibrin-ferment to pro- 
duce considerable constitutional disturbance. The virus, therefore, 
must be regarded as principally a chemical one, and not essentially 
different from that which produces surgical fever. 

The principal changes found at the post-mortem examination 
of such cases is the so-called "amyloid degeneration of the internal 
organs." It is a retrograde metamorphosis of the albuminoid con- 
stituents of the protoplasm of the cells. It usually attacks the small 
arteries, but extensive changes of this character are frequently seen 
in the spleen, the liver, the intestines, the kidneys, and the heart, 
and, as Billroth has shown, even in the lymphatic glands. It is 
supposed to be caused by the constant drain upon the body of the 
alkaline salts, notably the compounds of potassium, produced by 
the suppurative discharge. 

It is important to be able to recognize the presence of such 
changes during life, for the existence of such a degeneration of the 
internal organs would clearly be a contraindication for operative 
interference; for the disease, when once established, is generally 
regarded as incurable. It would obviously be useless to attempt 
the radical cure of hip- or knee-joint disease by resection if such 



33° SURGICAL PATHOLOGY AND THERAPEUTICS. 

a complication existed. The condition of the liver or the spleen 
should carefully be looked into, and any enlargement of those 
organs be sought for. An examination of the urine would throw 
valuable light upon the presence of organic diseases of the kidney. 
Amyloid or albuminoid degeneration of the mucous membrane of 
the intestinal canal would possibly betray itself by diarrhoea, by 
paleness of the discharges, or by the absence of bile, and by other 
symptoms of disordered function. 

Severe operations in the later stages of cases of long-standing 
suppuration are rarely attempted by surgeons of experience. It is 
in the early stages of suppuration that prompt interference should 
take place. A counter-opening in one of the lips of a wound, with 
insertion of a drainage-tube in acute cases, will usually suffice to 
prevent further trouble. When the pus begins to burrow the 
micrococci appear to be endowed with unusual activity, and ex- 
tensive sinuses form in various directions unless further progress 
is checked by free openings with the knife extending to the extrem- 
ity of the cavity and freely exposing its walls. The walls should 
then be curetted carefully to remove all bacterial growth, and 
should be brought into contact with antiseptic agents until 
healthy granulations have formed. 

In compound fractures and in wounds of joints this treatment 
becomes at times extremely difficult to carry out, and the question 
of resection or of amputation is often raised. The latter operation 
should not, however, be proposed to the patient under these circum- 
stances, except for the purpose of saving life. Many a poor man 
who has risked his life to save his leg has finally triumphed over 
his disease: when it is realized what a terrible misfortune the loss 
of a limb is to the laboring man, the surgeon may well hesitate to 
advise amputation unless confident that death is staring the patient 
in the face. 

Frequently an old-standing case of suppurative cellulitis — such, 
for instance, as follows a compound fracture — may be much bene- 
fited by a complete change of surroundings. Removal even to 
another bed may be sufficient — better still, to another room or 
ward; and occasionally the patient may be placed for several hours 
at a time daily in the open air. Free stimulation and the abun- 
dant use of easily-digested food will help maintain the strength, 
and during convalescence the employment of iron may repair the 
degenerated blood-corpuscles and tissues, and may give force to the 
appetite and the powers of digestion. 

A type of fever which may appropriately be considered here, 



SURGICAL FEVERS. 331 

although not strictly belonging to the surgical fevers, so called, is 
that which accompanies lymphangitis following a "poisoned 
wound." If the wound be freshly made and protective inflamma- 
tion has not closed the open channels which lead from it to various 
parts of the body, there exist conditions most favorable for rapid 
absorption of poisonous substances. The route through which this 
absorption occurs is usually the lymphatic system, and consequently 
a prominent feature of the absorption is the lymphangitis which 
marks the progress of the poison from its point of entrance toward 
the centre of the body. The circumstances under which this form 
of poisoning is most likely to occur is the accidental wounding of 
the hands of the surgeon or pathologist. The cause of this type 
of fever is probably very similar to that which gives rise to surgi- 
cal fever; that is, it is largely chemical in its nature. It is probable 
that a bacterial invasion also occurs to a considerable extent, but 
in the type under consideration bacteria do not play any prominent 
part, as the fever subsides quickly the moment the supply of mor- 
bid material is cut off by surgical interference. There are, how- 
ever, occasions when bacteria play a more important role under 
these circumstances, but these will be considered in the next 
chapter. 

The study of surgical fevers would not be complete without con- 
sidering that variety which has so long been regarded as an exam- 
ple of the purely nervous origin of fever — a fever in which bac- 
teria and ptomaines consequently play little or no part. The most 
conspicuous example which has been brought forward to illustrate 
the type is the so-called urethral fever. 

It is a not uncommon occurrence for the patient, after a cath- 
eter has been passed, to have the same evening a rapid rise of tem- 
perature, ushered in by a chill. The febrile disturbance, however, 
soon runs its course, and a couple of days usually suffice to restore 
the temperature to its normal condition. Some patients are much 
more susceptible than others, but the occurrence of the "urethral 
chill" is so frequent that in many hospitals it is a custom to 
administer a dose of quinine immediately after the use of the cath- 
eter to ward off this complication. 

Unfortunately, the fever is not always of this mild type, and 
may even be attended with fatal results, as the accompanying case 
will show: 

A man of middle age was admitted to the writer's ward with a stricture 
of the urethra. On examination his skin was found to be covered with a 
syphilitic papular eruption. There was a watering-pot perineum, and on the 



332 SURGICAL PATHOLOGY AND THERAPEUTICS. 

introduction of a polished steel sound a stricture of medium calibre was 
encountered in the penile portion of the urethra. He was an " old stager," 
accustomed to urethral surgery, and bore without flinching the examination. 
An attempt was made to pass the sound through the stricture, which, how- 
ever, would not yield, and, as the pain was severe, the attempt was aban- 
doned. No blood was drawn. The next morning the patient's temperature 
was 104 F. and the amount of urine was exceedingly small. Death occurred 
within twent5 r -four hours, and at the autopsy the only lesion found was an 
intense congestion of both kidneys. There was no cystitis, there were no 
marks of violence to the urethra, and there was no evidence of "surgical 
kidney. ' ' 

It seems difficult to interpret such a case in any other way than 
by assuming that an intensely powerful irritation was applied to 
the nerves supplying the urethra, which by reflex action produced 
congestion of a kidney already weakened by constitutional disease. 
The fever may have been due to the absorption of products liber- 
ated by the morbid changes set in action in an inflamed organ, 
and death was caused chiefly by uraemia. 

Undoubtedly, many cases of urethral fever are due to an inflam- 
mation of the kidneys, which have become gradually disorganized 
by the bacterial invasion, which, starting from some urethral in- 
flammation, has gradually, with the lapse of years, worked its way 
along the genito-urinary tract. 

Operations upon patients with surgical kidneys, as such kidneys 
are called, are to be avoided; but even in these cases it seems prob- 
able that a powerful reflex action of the nervous system has so far 
affected the vitality of the organ as to enable the bacteria to exert 
their morbid action upon it; in other words, that the nervous sys- 
tem plays a not inconsiderable part in the production of the inflam- 
matory process. 

Occasionally there is seen a genuine case of acute bacterial inva- 
sion of the kidneys, which appears to be the cause of a train of 
symptoms such as have been sketched. 

Litten not long ago reported two cases — a boy and a girl — of 
renal mycosis: 

The boy was taken ill with a slight gastro-intestinal catarrh, and on the 
third day a rigor and considerable pyrexia occurred. He passed on that day 
about seven ounces of albuminous urine, but on the three following days 
passed only three ounces . The pyrexia assumed a remittent type. The liver 
and spleen were found to be enlarged. The patient became delirious, uncon- 
scious, and death occurred after a series of convulsions. The girl's symp- 
toms were almost identical. At the post-mortem examinations a few bac- 
teria were found in the liver and spleen, but the kidneys were filled with 
them to such an extent that they could not be injected. 



SURGICAL FEVERS. 333 

The true interpretation of such cases as these may be learned in 
the succeeding chapters, where it will be found that the kidney is 
considered by some to be one of the most active organs in the elim- 
ination of micro-organisms from the circulation and the tissues of 
the body when once an invasion has taken place, which in the 
above-mentioned cases appears to have occurred from the intestinal 
tract. 

Notwithstanding that many a supposed case of genito-urinary 
congestion due to nervous origin has satisfactorily been demon- 
strated as due to the presence of bacteria, it seems probable that 
not all cases can be explained in this way, and that there exist a 
certain number which are due to nerve-action. 

The nervous origin of inflammation and fever has strongly been 
advocated by no less a person than Iyister himself. The examples 
he gives are numerous and interesting. He seems, indeed, almost 
to take the ground that the nerves play a more important part in 
certain inflammations than do bacteria. Ogston vigorously opposes 
this theory. But it seems to the writer that Lister rightly at- 
tempted to check the growing tendency to ascribe all morbid 
processes to the presence of bacteria, and thus to overlook facts 
which give many valuable hints in the management of disease. 

By way of recapitulation it may be said that aseptic fever is due 
to the absorption of substances so slightly altered as to resemble 
closely the normal tissues or fluids of the body. In other types of 
surgical fever, such as traumatic and suppurative fever, it will be 
found that, in addition to the above-mentioned causes, there is a 
pyrogenous or fever-producing material which is manufactured 
through the agency of micro-organisms and belongs to the class of 
substances known as ptomaines. The bacteria found in sloughing 
or suppurating wounds are also absorbed at the same time, but in 
small numbers and with no great regularity, and they do not 
appear to exert any special influence upon these morbid processes. 



XIV. SEPTICEMIA. 

In addition to the surgical fevers considered in the preceding 
chapter, there are still to be studied two types of fever which, on 
account of their fatal character, have since early times been the 
subject of anxious thought and careful investigation, and have 
greatly stimulated modern research. Among the chief blessings 
that have followed the introduction of the antiseptic treatment of 
wounds has been the almost total abolition of these pests from hos- 
pital wards. They are, however, still occasionally seen when 
antisepsis has failed, owing perhaps to the nature of the wound or 
the very unfavorable conditions under which it has been treated. 
Such cases will, for instance, probably be found in hospital reports 
of future military campaigns, although each succeeding war has 
shown wonderful improvement in the success attending the efforts 
to eradicate preventible disease. A brief reference to these fevers 
will enable the reader more intelligently to study the problems pre- 
senting themselves for investigation and the results that have been 
obtained throwing light upon their etiology. 

Billroth has well said that septicaemia bears the same relation to 
surgical or traumatic fever that pyaemia does to suppurative fever, 
each being the malignant type of the corresponding milder affec- 
tion. As has been pointed out in the last chapter, surgical fever 
occurs in the early stages of the healing of the wound, before sup- 
puration is established, and it is principally due to putrefactive 
changes of greater or lesser degree occurring before suppuration 
finally establishes itself and cleans the wound. In the same way 
septicaemia is dependent upon the contingency of septic infection 
of the wound with its accompanying changes, and it is from com- 
plications of this character that a fatal disease is developed in the 
system. When suppuration is established the materials susceptible 
of putrefactive change are washed away, and when a fatal form of 
infection occurs at this later period it will be found that the morbid 
process now developed, both clinically and anatomically, is very 
different in its nature from septicaemia: the name pycemia is 
intended to indicate close association with the process of suppu- 
ration. 

334 



SEPTICEMIA. 335 

The following account briefly describes a case of septicaemia 
such as occurred in the writer's experience: 

A 3*oung, healthy man presented himself at the hospital some years ago 
with a sarcoma on the dorsnm of the foot. Amputation was performed at the 
point of election — that is, through the lower third of the tibia. The wound 
was dressed antiseptically, but the traumatic-fever curve was from the begin- 
ning a high one: the patient did not complain of pain or distress, but 
appeared to be suffering from some constitutional disturbance. The wound 
was opened and a thin, somewhat foul serum escaped ; it was then thoroughly 
disinfected and moist dressings applied to favor discharge. The temperature, 
however, continued to rise without any remission : the patient gradually 
became delirious, then comatose, and died on the fourth day. At the autopsy 
no lesion of importance was discovered and suppuration had not established 
itself in the wound. Although aseptic precautions had been taken in carry- 
ing out the operation, infection of the wound took place, which infection 
was finally traced to a dirty sponge. 

This case presents an example of an infection of the system 
through a wound propagating itself within the body, and progress- 
ing through a series of changes to a fatal termination, notwith- 
standing the efforts directed toward the removal of the poison at its 
point of entrance. Such a case seems to offer simple conditions 
for the purposes of study, but of all the surgical infectious diseases 
not one proved a problem so difficult to explain, and there are many 
points concerning the origin of septicaemia that still are obscure. 

It will be necessary, therefore, to enter somewhat elaborately 
into a historical account of the investigations into the etiology 
of septicaemia, which involves a consideration of much that is of 
importance in the early study of the "germ-theory" of disease. 

Among the earliest records of septicaemia is that of Hippoc- 
rates, who recognized it as a constitutional disturbance accom- 
panying putrefaction in wounds, particularly head-injuries and 
fractures. It was known in the Middle Ages as febris putrida. 
The distinction between septicaemia and pyaemia was not carefully 
drawn, however, and it was not until the nineteenth century that 
the current name was first given to it. 

Piorry first introduced the term septicemia (from oynTcxoz, 
putrid, aifia, blood), and, notwithstanding various changes, this 
name substantially has been preserved until the present time. 

In the early part of the present century attempts at experimen- 
tal investigation of the origin of the disease were made upon ani- 
mals. Gaspard injected putrefying fluids into the tissue of animals, 
with the result of obtaining a disease resembling septicaemia. The 
blood of an animal dead of the disease thus produced was injected 



336 SURGICAL PATHOLOGY AND THERAPEUTICS. 

into another animal, and, the disease being thus transmitted, he 
concluded that the blood of the second animal had become 
infective. 

In 1850, Davaine's demonstration of the anthrax bacillus in the 
blood of animals affected with splenic fever produced a profound 
impression upon the scientific world, and the sentiment of the time 
was strongly set in favor of the ' ' germ-theory ' ' of the disease. 

The very able investigations, in 1856, of Panum, a Danish 
observer, could not be overlooked, however, and it soon became a 
question whether septicaemia should, after all, be reckoned among 
the bacterial diseases. Panum performed upon animals a series of 
inoculations with decomposing tissues of various kinds, such as 
brain, muscle, connective tissue, etc. He obtained a putrid poison 
which did not lose its strength by filtering, and which was not 
destroyed after two-thirds of it had been evaporated and the 
remainder subjected to a temperature of ioo° C. for eleven hours. 
He concluded that bacteria were not the poisonous principle, but 
that a chemical substance existed (soluble in water) which would 
produce the symptoms of putrid or septic infection. The intensity 
of this poison he compared to the venom of serpents and to curare. 

Attempts were now made to study this ' ' putrid poison ' ' more 
accurately, and Bergmann thought he had obtained from putrid 
yeast and decomposed blood the active principle in the form of 
needle-like crystals, to which he gave the name sulphate of sepsin, 
0.01 gramme of which, dissolved in water and injected into the 
veins of dogs, produced gastro-enteritis. 

Pasteur believed the active agent concerned in the production 
of septicaemia to be an organism which he called the " vibrion sep- 
tique." An apparent confirmation of Pasteur's views was obtained 
by his filtration of blood containing the bacilli of anthrax through 
earthen cylinders, an inoculation of animals with the filtrate fail- 
ing to produce any effect. It must be remembered, however, that 
anthrax is a true mycosis, the purest type of bacterial disease. 
Siegel, who successfully separated the bacteria from putrid fluids, 
showed that the injection of the filtrate into animals, although it 
did not produce genuine septicaemia, produced a putrid intoxica- 
tion — that is, a ptomaine-poisoning, a type of blood-poisoning. 

Coze and Feltz were among the first (1865) to carry out a series 
of inoculations on animals. They used the blood of a person who 
died of septicaemia, and succeeded in inoculating into another rab- 
bit the blood of a rabbit which died from the effects of the injection, 
and in transmitting the poison in this way from animal to animal. 



SEPTICAEMIA. 337 

Passing now to more recent investigations, it is found that 
Ogston takes the ground that infective inflammation, septicaemia, 
and pyaemia are all different phases of the same disease — namely, 
micrococcus-poisoning. In septicaemia he thinks one should not 
dwell too much upon the idea conveyed by the old-fashioned term 
44 blood-poisoning," but should remember that the points where 
poison lodges, where the various foci of infection consequently 
exist, are in the tissues rather than in the blood, and that from 
these various sources micrococci to some extent, but chiefly pto- 
maines, pass into the circulation and are distributed over the body. 
If the poison is strong enough, the micrococci colonize, and there 
are produced the metastatic abscesses of pyaemia. 

Koch injected putrefying fluids, such as blood and meat-infu- 
sions, under the skin of the back in mice. In a certain number 
of cases marked symptoms were observed in these animals imme- 
diately after the injection, and death took place in from four to 
eight hours. If blood taken from the right auricle of an injected 
mouse was introduced into another mouse, no effect was produced; 
no bacteria were found in the blood nor in the internal organs. 
"The animal," he says, "has died not from an infective disease, 
but simply from the effects of a chemical poison." This assertion 
was proved by diminishing the dose, the symptoms diminishing 
correspondingly in intensity, until they were found to be absent 
entirely when only one or two drops were injected. 

Another group of cases, however, would begin to show symp- 
toms after the lapse of twenty-four hours, even when less than a 
drop of putrid fluid had been used. Symptoms of septicaemia then 
developed themselves, and the animal died in from forty to sixty 
hours after the inoculation. Even so small a quantity of fluid as 
one-tenth of a drop taken from the subcutaneous oedema or from 
the heart of such an animal, and inoculated into another mouse, 
produced the same group of symptoms after the same period of 
incubation. These inoculations were successfully repeated through 
a series of seventeen individuals. Koch succeeded also in obtain- 
ing a disease resembling septicaemia in rabbits. In this case the 
organisms were micrococci, considerably smaller than pus-cocci. 
These organisms were well shown in the glomeruli of the kidney 
and in extravasations found on the surface of the intestines. 

Here, then, are found two distinct types of disease experimen- 
tally produced: First, putrid infection or intoxication or poisoning 
by a chemical substance, a disease similar to that described by 
Duncan as saprczmia (paacpbs, putrid, at(ia ) blood), where the symp* 
22 



33 8 SURGICAL PATHOLOGY AND THERAPEUTICS. 

toms begin immediately and correspond in intensity to the dose of 
the poison. Secondly, septic infection, bacterial poisoning, or, as 
it is sometimes called, "mycosis" (from /i^c, a fungus), coming 
on after an interval, but progressing to a fatal termination inde- 
pendently of the condition of the wound. The form of bacteria is 
not always the same, and Koch, moreover, found that certain ani- 
mals — as, for instance, the field-mouse — were quite insusceptible to 
the septicaemia of the house-mouse; in other words, that no one 
form of bacteria was found that could be regarded as the specific 
organism of septicaemia. 

Blood-cultures taken by Rosenbach from cases of septicaemia in 
man proved sterile. Staphylococci were found, however, in the 
blood in three cases of human septicaemia. This failure to obtain 
a constant organism, he thinks, does not prove that with improved 
methods we may not be able to demonstrate its bacterial origin. 
As a result of his investigations Rosenbach concludes that in most 
cases of human septicaemia we do not have bacteria-1 invasion; the 
symptoms are more likely due to the absorption of poisonous fer- 
ments or ptomaines. 

Von Biselberg, an assistant of Billroth, examined the blood in 
many cases of septic fever, and was able to demonstrate the presence 
of staphylococci and streptococci. Cheyne, who quotes this observa- 
tion, regards it simply as an example of the accidental presence of 
these organisms when they were apparently doing no harm. Besser 
examined during life the blood of 16 patients afflicted with trau- 
matic septicaemia, and found streptococci in 4 of them after death. 
They were present in the blood in 7 out of 15 cases ; in the organs, 
in 16 out of 18 cases. This author thinks that septicaemia is pro- 
duced solely by the streptococcus. 

Baumgarten is in doubt as to whether the symptoms of septicae- 
mia are exclusively due to bacterial invasion or whether some of 
them may not be caused by ptomaines. The evidence shows that 
the bacteria are not numerous enough to produce all the symptoms 
of the disease. He has not been able to get bacteria from special 
cultures of fragments of organs removed for that purpose. If it 
had been possible to find the bacteria, such a method ought to have 
given tangible evidence of their presence. He cannot believe that 
such symptoms as febrile disturbance, disorders of the nervous 
system, and cloudy swelling of the heart, liver, and kidneys are 
due to the presence of bacteria. Baumgarten is inclined to think, 
therefore, that the toxic element predominates and exerts a poison- 
ous influence before the bacteria have an opportunity to multiply. 



SEPTICEMIA. 339 

Gusseiibauer recognizes the difference between septic intoxica- 
tion and septic infection, but thinks that at the bedside there may 
generally be seen a mixture of the two types. He has repeatedly 
been able to make cultures of micrococci from the blood of septi- 
cemic patients, and to observe them microscopically in the freshly- 
drawn blood. 

According to Neelsen, in true septicaemia bacteria exist in the 
body, but they are hard to find. The most certain method of 
demonstrating them is to remove fragments of organs and to 
allow them to brew at bodily temperatures. He is obliged to 
assume in these cases that a poison of great intensity is given off 
by the organisms, which poison kills before they can multiply to 
any great extent — a sort of "toxic mycosis." 

Vaughn thinks that the bacteria may produce a ptomaine not 
exactly in this way, but by splitting up pre-existing and complex 
compounds in the body, and that, according to the latest view, each 
specific or pathogenic form of bacteria produces its own character- 
istic poison or poisons. 

The opinions expressed by the authors above quoted show that 
surgical knowledge of the poison of septicaemia is yet incomplete. 
There seems to be no question about the existence of a purely 
chemical or ptomaine poisoning in certain cases, for not only is the 
type obtained in its purity in laboratory experiments upon animals, 
but it is also seen at the bedside under circumstances that leave 
little doubt as to its true character. 

A bacterial form of septicaemia is found also in animals. The 
difficulty in finding micro-organisms in the blood of human beings 
affected with septicaemia appears to be due to the fact that they are 
rapidly swept through the large vessels, and are therefore found in 
the general circulation during but brief periods of time. They 
accumulate, however, in the capillaries, and there have an oppor- 
tunity to multiply. When the process is unusually virulent, and 
the conditions for the development of the organisms are therefore 
favorable, they may eventually be found in large numbers in the 
general circulation. It is for this reason that the presence of bac- 
teria in the blood of septicaemic persons is observed only under 
very favorable conditions. The organism which is almost always 
found in the blood of septic cases is the streptococcus pyogenes, 
and other forms of bacteria are but rarely observed. 

True septicaemia in man follows closely the progressive charac- 
ter of the symptoms observed in bacterial septicaemia of animals: 
an interval follows the moment of infection, and the disease then 



34° SURGICAL PATHOLOGY AND THERAPEUTICS. 

progresses to its fatal termination, producing its characteristic 
symptoms in their regular order, notwithstanding what may be 
done at the point of entrance of the organisms to check it. Here 
is a process going on inside the body independently of the wound. 
Whether this process is caused solely by the multiplication of bac- 
teria, or is dependent in part upon the liberation of intensely pow- 
erful poisons, or is due to some ferment-like substance capable of 
reproducing itself, like the poison of the serpent, as in diphtheria 
and tetanus, much more extensive studies upon the human subject 
will be necessary to enable us to say. 

Harrington reports the case of a surgeon in whom septicaemia developed 
after a slight injury to the finger by a needle during an operation for " puru- 
lent peritonitis, probably of appendicular origin." Death occurred on the 
sixth day. Pure growths of streptococci were obtained by Stone from cultures 
taken from the heart's blood, the liver, the kidney, the spleen, and the subcu- 




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%'' A 








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jr 1G> 67.— Infiltration of Muscular Tissue with Streptococci in a case of Septicaemia of Man. 
The blood-vessels contain numerous leucocytes, but none are found in the surrounding 
connective tissue. 

taneous tissues of the thigh (Fig. 8). Sections of the muscles of the thigh 
showed that all the intermuscular spaces were distended by a mass of bac- 
teria, and there was no infiltration of leucocytes into the tissues, though the 
blood-vessels seemed to contain an unusually large number of white blood- 
corpuscles (Fig. 67). In sections of the kidney the bacteria were demon- 
strated with considerable difficulty, in spite of the fact that the amount of 
kidney-substance that could be picked up with a small wire loop gave 
over one hundred colonies when planted. When found the cocci were in the 



SEPTICAEMIA. 341 

intercellular spaces. Neither in the kidney nor in the muscular tissue was 
there any suggestion of arrangement of the cocci in chains. This was to be 
seen only when cultivated outside of the body. 

The next point to be considered is the mode of entrance of the 
poison into the body. Of course by far the most frequent route of 
introduction, as the surgeon sees it, is through a wound which has 
become infected by the failure of antiseptic precautions in an ope- 
ration or from the exposure which necessarily accompanies a severe 
injury. 

The conditions in a wound favorable for septicaemia are those 
which accompany gangrene or sloughing of the tissue, although 
some of the most malignant types of the disease may occur when 
the wound has been insignificant in size. Septic infection may 
accompany other traumatic infective diseases, such as erysipelas and 
hospital gangrene, particularly the latter, and sudden putrefaction 
of the contents of a wound, such as is likely to occur in an infected 
wound containing blood-clots or imprisoned pus. Such cases as 
these would probably be followed by that variety of blood-poison- 
ing known as saprczmia. 

But it is not through wounds alone that the virus finds its way 
into the body. The skin is indeed a sure protection, when in its 
normal condition, against the invasion of microbes or ptomaines. 
The mucous membranes are not so protective in character. The 
intestinal canal is filled with bacteria of various kinds in its entire 
extent, and under conditions favorable to them they will often 
make a raid upon the interior of the body. In individuals of 
broken-down and enfeebled constitutions it is not improbable that 
an examination of the blood at intervals would show the presence 
of micrococci. As Cheyne has shown, a local injury or an inflam- 
mation will furnish a lodging for these wandering organisms, and 
a focus of infective inflammation will at once be established by 
which a general infection of the system may be produced. Chau- 
veau has, in fact, artificially imitated such a disease by injecting 
putrid material into the veins of animals, and in then producing a 
local inflammation, such as fracture of a bone. Such cases as these 
are occasionally seen arising apparently spontaneously in man, and 
they were at one time supposed to be examples of "spontaneous 
septicaemia." In these cases an acute or infective inflammation is 
usually found somewhere to account for the constitutional symp- 
toms. In former times these foci were often overlooked, perhaps 
partly on account of the violence of the constitutional symptoms, 
and it was therefore supposed that a sort of miasmatic infection had 



34 2 SURGICAL PATHOLOGY AND THERAPEUTICS. 

taken place. The origin of such forms can now be traced to 
various well-recognized surgical affections. 

One of the commonest of these affections is acute osteomyelitis, 
which occurs in the long bones of the young following slight 
injuries or following exposure in individuals of enfeebled constitu- 
tion. The onset of such inflammation is exceedingly violent, and 
the conditions for absorption of the virus are unusually favorable. 
A certain number of such cases die in the early stages of the dis- 
ease before even suppuration is established. Similar inflammations 
may occur in other parts of the body, as will be seen presently. 

It can only be assumed, by way of explanation of the origin of 
these cases, that an invasion of bacteria has taken place through 
the intestinal canal, and that they have obtained lodgment at 
some bruised or weakened or inflamed spot, or that the organisms 
have obtained an entrance through some minute wound. 

But in some cases there is direct proof that an infection takes 
place through the intestinal mucous membrane. Sepsis intestinalis 
is now a well-recognized affection, resulting usually from the 
absorption of poisonous substances in food. 

Vaughn gives an excellent description of the result of poisoning 
by eating canned meats, sausages, ice-cream, and cheese. In the 
latter substance he found a ptomaine that he named tyrotoxicon, 
which is now generally regarded as the active principle in many of 
these cases of poisoning. This observation would place this group 
of affections in the class of sapraemia or poisoning by a chemical 
substance — an "intoxication." It seems difficult to believe that 
the numerous intestinal bacteria play no part in the process, and 
that in addition to the "intoxication" there is not also, to some 
extent, "mycosis" of the system. This is, indeed, the view of 
many observers, but Vaughn's studies led him to relegate the intes- 
tinal bacteria to quite a subordinate role in the process. 

With regard to the respiratory tract as an avenue of entrance 
for the poison of septicaemia, it does not, at first view, seem prob- 
able that an example of such a mode of infection should ever 
occur. Ogston, however, recognizes as one of the mildest forms 
of sapraemia the sickness and nausea produced by a bad smell, 
which, as he says, is but a ptomaine of putridity, and which 
under certain contingencies may produce serious symptoms. Some 
of the cases of fever supposed to be due to sewer gas do not differ 
essentially from the more strictly surgical forms of blood-poisoning. 
Gussenbauer suggests that the inhalation of such gases may predis- 
pose the system to the invasion of bacteria. A curious fact in this 



SEPTICEMIA. 343 

connection is the supposed immunity acquired against infection of 
this kind by individuals who are habitually exposed to foul odors, 
as those who work in the sewers or in the dissecting-room. To the 
surgeon such a mode of infection is comparatively rare; the physi- 
cian, however, meets with it in many of the epidemic forms of 
disease. 

Examples of infection through the genito-urinary tract occur 
rarely when this region is still in a normal condition. The follow- 
ing is perhaps such a case: 

A man thirty years of age entered the hospital with symptoms of stone 
of a few months' standing. A phosphatic calculus of about 80 grains was 
removed 03- litholapaxy, the operation lasting tw T enty minutes. No blood 
flowed in the urine after or during the operation. Examination of the urine 
showed no disease of the kidneys. The patient's general health had always 
been good. The temperature, however, ranged in the neighborhood of 105 
F. for a week, during which time the urine was loaded with bacteria. The 
fever gradually subsided, the bacteria disappeared, and the man made a rapid 
recover}- at the end of that time. 

Imperfect asepsis had been preserved during the operation in 
all probability, and infection through the urinary tract had conse- 
quently taken place. The danger of operating upon those whose 
kidneys are in the condition known as ' ' surgical ' ' is familiar to 
all surgeons. In this case an organ already contending with bac- 
terial inflammation of a chronic character suddenly ceases to resist 
invasion as the result of the shock and depressing influence of a 
surgical operation or of a fresh infection. 

Passing now to the symptoms of septic infection, the purely 
toxic form will first be considered, inasmuch as some authors, par- 
ticularly recent writers, dwell upon the importance of distinguish- 
ing cases of saprsemia, or pure ptomaine-poisoning, from the other 
forms, although the writer does not feel that we are yet fully justi- 
fied in recognizing this as a separate disease in the present state of 
our knowledge. 

The most typical example of saprcsmia is usually found in the 
obstetric wards, and is there due to the putrefaction of retained 
clots or placental fragments in the uterus. The poison may be 
absorbed from the mucous membranes of the vagina or the uterus 
with their rich lymphatic connections, or through open wounds in 
the vaginal mucous membrane, or at the point of attachment of 
the placenta, or through the uterine sinuses directly into the circu- 
lation. The preliminary chill, which usually marks the onset of 
many acute forms, is generally wanting. There is, however, a 



344 SURGICAL PATHOLOGY AND THERAPEUTICS. 

rapid rise of temperature to ioi° or 103 F. , rarely higher. The 
changes in the blood are marked, the patient becoming anaemic; 
there is some leucocytosis, but the chief change is in the number 
of red corpuscles, that varies directly with the degree of blood- 
poisoning. In the early stages there is headache with nausea and 
vomiting, and later diarrhoea and purging. 

The blood, the nervous system, and the intestinal canal appear 
to be the parts chiefly attacked by the poison. The inflammatory 
condition of the intestinal canal may be due in part to an effort 
of the system to eliminate the virus. The temperature is contin- 
uously high, and delirium supervenes, followed by coma in fatal 
cases. 

In no disease are the results of treatment more striking and 
satisfactory than in this, a prompt removal of the putrefying con- 
tents of the uterus being followed in a few hours by a fall of tem- 
perature, a disappearance of all alarming symptoms, and a return 
to a comfortable condition. 

The removal of the clots or placental remains can be effected 
either manually and instrumentally or by an antiseptic douche, 
which should carefully be introduced into the interior of the ute- 
rus, care being also taken against the introduction of air into the 
uterine sinuses. This douche should consist, according to Duncan, 
in cases where the state of putrefaction is advanced and the lochia 
consequently are exceedingly foul, in the injection of a solution 
(1 : 40) of carbolic acid. The writer takes occasion, however, to 
warn the surgeon that solutions of this strength are liable to pro- 
duce symptoms of carbolic poisoning if used in large quantities or 
in repeated doses, and that in surgery such solutions are now used 
less frequently than formerly. Often a dose of ergot may alone be 
sufficient to evacuate the uterus, in which case it will be well to be 
content with a vaginal injection. 

The writer has dwelt upon a subject not strictly surgical 
because there occurs in the puerperal state the best example of 
this type of poisoning, and the lesson it conveys as to treatment 
is so obvious as not easily to be forgotten. The surgeon cannot 
always expect, however, to accomplish so satisfactory a cure, for not 
infrequently the poison of septicaemia will be mingled with that of 
sapraemia, and the improvement will therefore be but temporary, 
unfavorable symptoms reappearing when the period of incubation 
has passed and when the virus is beginning to act upon the system. 

Unfortunately, cases of the pure sapraemic type are rare in sur- 
gery. The condition most favorable in the wound for the develop- 



SEPTICAEMIA. 



345 



ment of the disease is the presence of unusually large quantities 
of blood-clot or serum, or of gangrenous or sloughing tissues, 
particularly in such situations as prevent an easy access of the 
pent-up materials to the surface. Such conditions occasionally 
occur after opening a deep-seated abscess, when large veins have 
been exposed, or in the peritoneal cavity after the removal of 
abdominal tumors. 

All such fluids, if they are preserved in an aseptic condition, will 
produce nothing more than a slight rise of temperature (aseptic 
fever) if absorbed, but if allowed to remain stagnant they are, in 
certain situations — as in the vicinity of the intestinal canal — 
extremely liable to bacterial invasion, even though external asepsis 
has been successfully carried out. It is, therefore, highly important 
that thorough drainage should be provided when a tendency to 
oozing of blood is liable to occur, particularly in the peritoneal 
cavity when the wonderfully rapid absorbing action of the perito- 
neum has been impaired. The accompanying chart represents the 
fever-curve in a case of resection of the knee-joint. On the fourth 
day an infection of the wound occurred from a concealed sinus : 
opening and disinfection of the wound and sinus were promptly 
followed by a fall of temperature (Fig. 68). 



104 

103 

10 

10 

100 

99 

98 



96 



A 


1 


2 


3 


4 


5 


6 


7 


8 


9 


10 


II 


12 


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Fig. 68. — Sapraemia. 



The constitutional disturbance in true septicemia does not differ 
materially from that just mentioned in the initial stages. The main 
difference consists in the more gradual onset of the disease, a period 
of incubation existing before the presence of the virus makes itself 
felt. Usually after a capital operation there will be considerable 
elevation of temperature even in favorable cases. At the end of 



346 



SURGICAL PATHOLOGY AND THERAPEUTICS. 



forty-eight hours, however, an improvement is usually expected T 
and for this reason, probably, there has arisen the popular belief 
that by the third day the surgeon is able to tell whether the patient 
is going to make an uncomplicated and rapid recovery or not. If 
at this time the temperature still remains high, or even increases, 
some unfavorable conditions are liable to be discovered existing in 
the wound, and on removing the dressing it will probably be 
found that a septic infection has taken place, and that one or more 
of the symptoms of infective inflammation are present. Occasion- 
ally the removal of stitches, or the effective disinfection and drain- 
age of the wound, may be sufficient to arrest further constitutional 
disturbance, but if genuine septicaemia develops, whatever may be 
done to the wound will be of little avail. 

With the access of fever which marks the beginning of the dis- 
ease there is, as in saprsemia, rarely a chill. Great prostration 
with headache and loss of appetite are soon followed by a typhoid- 
like indifference to all surroundings, a sort of stupor which renders 
the patient disinclined to make complaint as to his condition or 
feelings. The variations in the temperature correspond more or 
less accurately with the local condition of inflammation in the 
wound, but in some of the most malignant types the wound itself 
may be a trivial one and the amount of local septic disturbance 
may be comparatively small. There is a slight morning remission, 
but the fever is essentially a continued one, and it increases in 
degree, with perhaps a rapid rise at the end of a fatal case (Fig. 69). 



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Fig. 69. — Septicaemia. 

Gussenbauer calls attention to a certain class of cases in which 
there is subnormal temperature caused by the absorption of ammo- 
nia compounds, to which he gives the name "ammonsemia." Such 
a condition may be seen in connection with gangrenous hernia, and 



SEPTICEMIA. 347 

it has even been mistaken for shock. Many such cases doubtless 
belong to the sapraemic type of blood-poisoning, and, coming 
immediately after the operation or injury — such, for instance, as a 
penetrating gunshot wound of the abdomen — might readily give 
rise to such an error of diagnosis. Until Marion Sims called 
attention to the importance of laparotomy and to the toilet of the 
peritoneum in such cases, many a patient was undoubtedly allowed 
to die of supposed shock who otherwise might have been saved 
from a rapid poisoning. 

The effect which the poison has upon the lymphatic system is 
often well marked. In some cases there is seen from the begin- 
ning an acute lymphangitis, but this symptom belongs to a class 
of cases that will be considered later. In those cases which 
do not run a very rapid course an enlargement of the lymphatic 
glands may be noticed, particularly in the parts communicating 
directly with the wound. The entire lymphatic system will be 
more or less affected, and this condition will show itself in an en- 
largement of the spleen, which occasionally may become so hyper- 
trophied as to produce a distinct area of dulness. This is usually 
considered one of the characteristic symptoms of septicaemia, and 
should always be sought for. Another symptom characteristic of 
the disease is diarrhoea, which is usually not troublesome, and 
which can without difficulty be controlled by appropriate remedies. 
It is, however, frequently present, and may aid in the making of a 
diagnosis. At times the symptoms of gastro-enteritis are more 
acute, and sometimes there are rice-water discharges and vomiting, 
even when the route of the infection has not been through the 
intestinal canal, as in cases of canned-meat poisoning. 

A slight discoloration of the skin, with a faint yellow tinge of the 
conjunctivae, is sometimes seen in this disease, but the icterus is 
far less marked than in pyaemia. It is probable that the icterus is 
haematogenous, and is dependent upon the breaking down of the 
red corpuscles. In addition to this change in the blood there will 
probably also be found an increase in the number of white corpus- 
cles and the presence of micrococci, if the blood is examined 
during life. 

The pulse is rapid, and in dangerous cases is weak. Heart fail- 
ure is a complication that the surgeon must be prepared to meet. 
Symptoms of ulcerative endocarditis or of pericarditis are not likely 
to be observed. Scarlet eruptions of the skin are not uncommon, 
as has been shown in the remarks on surgical scarlet fever in the 
preceding chapter. The character of the rash may vary greatly 



34 8 SURGICAL PATHOLOGY AND THERAPEUTICS. 

from simple erythema to a pustular or hemorrhagic eruption. 
Hoffa has obtained from the skin of patients thus affected micro- 
cocci which were not pyogenic. The eruption is explained by him 
as being caused by them, their presence bringing about a capillary 
thrombosis in the vessels of the skin. It is hardly probable that 
the bacteria are present in sufficient numbers to produce an 
actual plugging of the vessels, but they probably act upon the 
fibrin-ferment in a way to produce a considerable coagulation of 
blood in the capillary vessels. A similar condition of the vessels 
of the retina gives rise to retinitis, which, however, does not make 
itself perceptible as a symptom, but it may sometimes be detected 
with the ophthalmoscope. 

These are the principal symptoms to be observed in severe 
examples of the disease. In milder forms many of them may be 
wanting. It is of course difficult to determine precisely when a 
case of surgical fever reaches that degree of severity which 
justifies the surgeon in giving a diagnosis of septicaemia, but 
undoubtedly many cases of genuine septic infection of the system 
are seen that eventually recover. In such cases the disease may 
assume a chronic form, running a course of two or three weeks' 
duration. A marked feature of this type is enlargement of the 
spleen, which may become a tumor of considerable size. The 
temperature does not rise so high as in the acute form. 

In the more malignant cases of septicaemia as the disease pro- 
gresses the wound will become unusually foul. Heuter, indeed, 
thought that the smell of a septicaemic patient was characteristic, 
and that a good surgeon ought to be able to make the diagnosis 
with his nose. With the powerful antiseptics of to-day he could 
hardly be expected to rely upon any such symptom. 

The temperature continues to rise, and the skin, which is first 
hot and dry, later becomes bathed in perspiration. The icteric hue 
will now be more marked. The prostration is at this time very 
great, and the patient has a listless expression. Septicaemic 
patients are not usually troublesome; they make but few com- 
plaints even when questioned as to their feelings. Their condition 
has been described as one of " euphoria." There is a dull expres- 
sion on the face that finally gives place to a sort of death stare, so 
familiar but unwelcome a sign to the unsuccessful operator. Bron- 
chial symptoms, with quickened respiration, make their appearance, 
diarrhoea continues, and the stools are offensive; the urine is con- 
centrated and scanty. Stupor is succeeded by delirium, and with 
the appearance of coma the patient becomes moribund. 



SEPTICEMIA. 349 

The post-mortem appearances of septicaemia show but little evi- 
dence of gross change in the internal organs. A more careful 
study of them, however, has shown that considerable alterations 
exist. Putrefaction of the cadaver takes place more rapidly than 
in the bodies of those who have died from any other disease. The 
blood is of a tar-like consistency and shows little tendency to coag- 
ulate; it contains innumerable bacteria, both micrococci and 
bacilli. Cultures taken from the interior of the heart and from the 
juice of internal organs often yield a growth of streptococci. 
Congestion of the pia mater is often found, and sometimes also 
punctiform extravasations in the deeper portions of the nerve- 
centres. As a rule, however, there are few changes seen in the 
nervous system. The muscles sometimes present a brownish dis- 
coloration. 

In chronic septicaemia there may be some evidence of endo- 
carditis in a thickening of the endocardium, but the ulcerative 
form of inflammation is not usually seen in this disease. Slight 
effusions in the pericardium and in the pleura are, however, found. 
There may be some oedema or passive congestion of the lung, and 
some increase in the secretions of the bronchi. The principal 
change is found in the alimentary canal: here the evidences of a 
gastro-intestinal catarrh are marked. There is a cloudy swelling 
of the submucous tissue of the stomach, particularly in puerperal 
cases. The principal points of inflammation of the intestines, 
according to Gaspard, are in the duodenum and the rectum. The 
membrane is swollen, of a mottled color, and is dotted over with 
punctiform hemorrhages. According to those who have experi- 
mented upon animals, this is one of the most constant symptoms 
of blood-poisoning. The spleen and lymphatic glands, particularly 
those of the mesentery, are enlarged. The enlargment of the spleen 
is generally well marked, its parenchyma being much darker than 
usual and greatly softened. The liver shows signs of putrefaction 
earlier than any other of the viscera, and at times the appearance 
known as e7nphyse?na of the liver indicates an advanced stage of 
decomposition, with the evolution of gas. This was very marked 
in a case the writer once saw, in which septicaemia followed the 
production of an abortion produced by inserting a dirty catheter 
into the uterus. A slight cloudy swelling of the liver is usually 
all that is seen. The kidneys are somewhat cedematous, and the 
tubuli uriniferi are more or less affected by a catarrhal inflamma- 
tion. Most observers agree that bacteria are abundantly found in 
the glomeruli — an evidence of the effort upon the part of nature to 



35° SURGICAL PATHOLOGY AND THERAPEUTICS. 

excrete the poison. The capillaries of an infected region are often 
plugged with streptococci, and the walls of larger vessels are infil- 
trated with them. Large numbers of these organisms are also 
found in the lymph-spaces of the connective tissue (Figs. 70 
and 71). 




Fig. 70. — Capillary Embolus of Streptococci in a Sarcoma. A round-cell infiltration is seen 
in the sarcomatous tissue about the embolus. (Case of fatal septicaemia.) 

The condition of the wound, as might be expected, is of the 
foulest description. Evidences of congestion or oedema of the sur- 
rounding tissues are apparent, and all these tissues are crowded 
with micrococci, and they are found also in the adjacent lymphatic 
glands, which are considerably enlarged. 

The writer has attempted to sketch the disease as it is usually 
seen after injuries or operations. There are, however, several 
variations in type which cannot be passed by without mention. 
Prominent among these variations is that form of septicaemia which 
usually follows a dissecting wound. Gussenbauer looks upon this 
as a form of ptomaine-poisoning, but Horsley does not accept 
this view. The rapidity with which symptoms make their appear- 
ance is due not to the absorption of a chemical poison, but rather 
to the unprotected nature of the tissue into which a fluid in a state 
of active decomposition is inoculated. Then the virus selects a 



SEPTICAEMIA. 351 

special route, by which it is rapidly carried to a distant point. 
More than one case of such a poisoning has occurred to a student 






1 



^ ^ v > ^ 



v 



# 






* •- 



Fig. 71. — Infiltration of Vessel-wall in Sarcoma. (Case of fatal septicaemia.) 

of the school during the writer's experience as a teacher. The fol- 
lowing account gives the salient points of one of these cases: 

A young man, tall and slender, about twenty-one years of age, had 
wounded himself slightly in the dissecting-room. He applied the next day 
to one of the surgeons at the hospital, complaining of pain in the shoulder. 
His condition was such that he was admitted to the hospital, and a consulta- 
tion was held the following day upon his case. At that time the whole arm 
was swollen ; red lines were seen running from an insignificant wound in the 
finger to the axilla. There was no sign of suppuration in the axillary glands, 
but the whole pectoral and scapular region was enormously swollen and 
cedematous. There was an anxious expression of countenance, high fever, 
and great prostration. Ether was given, and free incisions were made over 
the whole pectoral region, permitting the escape of a thin, slightly turbid 
serum. No pus was found anywhere. The patient was not benefited by the 
operation, and died the following day. At the autopsy no pathological 
changes of interest were recorded. 

Happily, cases of such malignant poisoning as this are not often 
met with. They bear a close resemblance to malignant oedema. 
Usually the poison gives evidence of its presence by an inflam- 
mation of the finger extending up the hand and invading the 
lymphatics, as shown by red markings upon the anterior aspect of 



352 SURGICAL PATHOLOGY AND THERAPEUTICS. 

the forearm and arm. An infective, followed by a suppurative, 
inflammation of the glands of the axilla occurs, and with the open- 
ing of the abscess further progress of the inflammation is arrested. 
The fever which accompanies this attack is rapid in its onset, and 
may be attended with sensations of chilliness, although a chill does 
not usually occur. There is great mental depression, and usually 
there is the appearance of anaemia with great loss of strength. The 
constitutional disturbance yields rapidly upon arrest of the inflam- 
mation, and in the milder types cannot be called a genuine "blood- 
poisoning;" that is, it hardly belongs to the forms of the septi- 
cemic or sapraemic type, but rather to the variety known as sur- 
gical or suppurative fever. 

Serious forms of septicaemia accompany such diseases as hos- 
pital gangrene and traumatic gangrene. In the latter case the 
acute type is found in its most characteristic form, but a descrip- 
tion of this complication is reserved for the chapter treating of 
Gangrene. 

There has already been alluded to the so-called ' ' spontaneous sep- 
ticaemia," and it has been shown that such a disease does not exist, 
but that in all cases a focus of inflammation is to be found some- 
where to account for the blood-poisoning. Many cases of suppu- 
ration of the appendix have doubtless passed in former times for 
spontaneous septicaemia. The absorption of the products of an 
inflammation around the appendix tainted with gangrenous and 
fecal extravasations must produce grave constitutional disturbance, 
particularly when the peritoneal cavity is invaded and this power- 
ful absorbing surface is exposed to the poison. The conditions 
for acute septicaemia are here exceptionally favorable. Undoubt- 
edly, a certain number of cases of perinephritic abscess could be 
rescued from this category. An individual in robust health is 
attacked with fever; there are no localizing symptoms; typhoid 
fever or pneumonia is suspected, but no characteristic signs of 
either of these diseases show themselves, and the patient succumbs 
in a few days, the strength of the poison having benumbed the 
senses to that extent that symptoms of local inflammation in the 
loin have not been complained of. 

Even at the present time, when a more generally diffused know- 
ledge and frequent autopsies have helped to clear up many obscure 
forms of disease, cases will occur that are still not easy to explain. 
The writer remembers one of this kind: 

A hard-working and temperate Irishman was attacked with subacute 
rheumatism in the ankle. The administration of salicylic acid did not 



SEPTICEMIA. 353 

serve to check the disease, and, as symptoms of polyarticular rheumatism 
with increased fever began to develop, he was removed to the hospital. A 
temporary improvement followed, but just as the rheumatic joints were 
improving an intense inflammation in the neighborhood of the right hip 
developed, reaching from the right iliac fossa halfway down the thigh. 
Acute septicaemia developed, and the patient was dead before forty-eight 
hours had elapsed. Unfortunately, an autopsy was not permitted. 

Acute osteomyelitis, which the above history suggests, has 
already been spoken of as a cause of septicaemia. 

In making a diagnosis of septicemia there must first of all be 
taken into consideration the condition of the wound. If there 
is found only an accumulation of blood-clot, the surgeon may have 
reason to hope that he has simply to deal with sapraemia. The 
high continued fever, the indifference of the patient to his sur- 
roundings, the absence of chills, and the symptoms of a general 
disturbance in the alimentary canal are the most important of the 
constitutional symptoms. The detection of an area of dulness in 
the region of the spleen, and of the presence of albumin and bac- 
teria in the urine, would aid in the diagnosis. But it must be 
confessed that there are no constant or very characteristic local 
symptoms, and that our opinion must be arrived at rather by a 
process of exclusion. 

The treatment of septicemia may be either local or general. 
The local treatment is largely prophylactic, and consists, it need 
hardly be said, in a strict observance of the principles of aseptic 
surgery. 

When once the diagnosis of septicaemia has been made, it will 
be the surgeon's duty carefully to examine the wound and to 
undertake as thorough disinfection as the strength of the patient 
will permit. Occlusive dressings must be abandoned; the wound 
must be opened sufficiently to expose all infected parts and to 
ensure free drainage of all putrefying discharges. A thorough 
washing of the wound may have considerable effect upon the 
fever if the poisoning be largely from ptomaines absorbed from 
the secretions, and some of the older methods invented by sur- 
geons who had a large experience in septic diseases should not be 
forgotten. Among these " the drip " has often done useful service — 
a device by means of which a constant current of fluid is carried 
over or through the wound. Over the part is suspended a cup from 
which depend a few strands of wick-yarn, and this will often prove 
sufficient for the purpose when a more elaborate arrangement of 
tubes is not possible. The antiseptic fluids applied in this way 
must be exceedingly weak, for a large quantity of a poisonous 

23 



354 SURGICAL PATHOLOGY AND THERAPEUTICS. 

substance would be absorbed, even though the solution were not 
strong; in fact, it would be desirable to use milder remedies, like 
boracic acid, and to rely chiefly upon the flow of pure water. 
If the wound is so situated that it can be submerged in water, 
weak antiseptic solutions will often prove most serviceable in 
finally overcoming the septic infection. Carbolic solutions, in 
the strength of i : iooo of water, or of sublimate, i : 50,000, will 
be sufficiently strong, or these solutions may be applied by means 
of hot fomentations or "antiseptic poultices." 

Strong solutions of carbolic acid (1 : 20) or peroxide of hydro- 
gen may be used in moderate quantities to disinfect the wound 
before the dressings are applied. It is probable that a very con- 
siderable amount of bacterial growth can be removed by thor- 
oughly scraping or curetting the surface of the wound, for the 
most superficial growths are not only removed, but the deeper 
tissues also are more thoroughly exposed to the action of the dis- 
infectants. 

Iodoform, which as a dressing is at its best on such occasions as 
this, may be applied freely to a sloughing wound, for the danger of 
poisoning is less than when directly in contact with healthy granu- 
lations. It can be applied on cotton or on gauze. Whether the 
agent be sublimate, carbolic acid, or iodoform, a careful watch, to 
avoid poisoning by these agents, should be kept upon disturbance 
of the bowels and on the condition of the urine. The more minute 
details of local treatment will be found in the chapter upon Infec- 
tive Inflammations. 

In the general treatment of the disease the surgeon has to deal 
with a fever accompanied with marked prostration of the strength 
and a deterioration of the blood. With the introduction of the 
antipyretic treatment of fever this method was also employed for 
surgical fevers, but with most unsatisfactory results ; at least, that 
has been the writer's experience. The relief from fever is exceed- 
ingly brief; at times no result whatever has been produced, and 
antipyretics do not appear to add in any way to the comfort of 
the patient, as is the case in typhoid fever. The disturbance of 
the fever-curve may also mislead the surgeon as to the patient's 
condition. These remedies are, however, not contraindicated in 
the milder forms of septicaemia, and they may often be productive 
of great relief to sleepless subjects. In the acute form valuable 
time may be wasted in watching their effect upon the disease. 

Great reliance must be placed upon nourishment and alcoholic 
stimulants. Nourishment must, of course, be of a nature suited 



SEPTICAEMIA. 355 

to the condition of the digestive system, and must be adminis- 
tered in small quantities and frequently. It is astonishing how 
much alcohol a patient in this condition is capable of absorbing 
without bad effects. The flushing of the face is a signal for its 
discontinuance or for its administration in smaller doses. The 
condition of the pulse will also be a good guide. Whether 
alcohol acts simply as a food or possesses antiseptic qualities 
has not been proved. According to Sternberg, the micrococcus 
requires the presence of 20 per cent, of alcohol for its destruction. 
The amount necessary to produce this action in the blood of a 
patient weighing one hundred and sixty pounds would be more 
than a quart — " a much larger quantity than the most enthusiastic 
advocate of its use would deem safe to administer." Alcohol to 
this amount has not infrequently been given in the course of 
twenty-four hours without ill effect, even in patients wholly unused 
to its action. This, of course, does not imply the presence of so 
large a quantity at any one time in the system; but it may be that 
in the living tissues the organism would find a less favorable soil 
for exerting its resisting powers against drug-action than when 
taken fresh from active artificial cultures. 

Heart failure must be guarded against, and heart-tonics may 
often be given with advantage when the pulse is weak and rapid. 
The tincture of digitalis, which may be tried in increasing doses 
for this purpose, is a drug that should perhaps be employed more 
freely by surgeons than it has been. 

The diarrhoea can be treated best with opium if it proves 
troublesome, and bismuth or tannin may be employed if necessary. 

In dealing with septicaemia it must be remembered that it is an 
essentially different disease from the surgical fevers. The latter 
are due to the absorption of virus constantly generated in the 
wound, and it is to this point, therefore, that attention should be 
directed. But in septicaemia there is, except in the case of saprae- 
mia, a constitutional disturbance which has become quite inde- 
pendent of its local origin — a disease in which the whole sys- 
tem, both blood and tissues, is involved, and which calls for the 
employment of all the resources at the surgeon's command. 



XV. PYAEMIA. 

This disease always accompanies suppuration, and, as will be 
seen, is nothing more or less than a complication of that disorder. 
The name pycemia, which is attributed to Piorry, was not given to 
it until the present century (1828). It is derived from the Greek 
(nvov, pus, aljua, blood). Velpeau described the disease under the 
name infection piiriilente, which term is still employed by the 
French. Although the nomenclature is of recent origin, the dis- 
ease itself was well known to the ancients, and it presents such 
marked clinical symptoms and pathological changes that the 
descriptions of the old writers leave no doubt in the mind as to 
the correctness of their observations. 

Hippocrates described that most characteristic of symptoms, the 
chill, and also the existence of icterus. Paracelsus described the 
inflammation of the joints. Ambrose Pare recognized the fact that 
compound fractures of the skull were sometimes followed by 
abscesses of the liver. Morgagni and Petit in the eighteenth cen- 
tury attempted to show that metastatic abscesses were caused by an 
actual penetration of pus into the blood. The next observation 
worthy of note was that of Hunter, who recognized the existence 
of phlebitis as one of the links in the chain of pathological 
events. Hunter supposed that there took place an adhesive phlebi- 
tis which prevented the entrance of pus into the blood, although 
the rupture of an abscess might occasionally cause this to occur. 
Suppuration of the inner wall of the vein he thought was the usual 
result of phlebitis, by which this protective influence would be pre- 
vented, and pus would be carried away in the blood-current, or 
inflammation might extend along the walls of the vessels to the 
heart, and thus cause death. He did not, however, express him- 
self clearly as to the relation of the metastatic abscesses to the 
inflammation of the veins. 

Cruveilhier was among the first to point out that the result of 
phlebitis was the coagulation of blood in the veins. The discussion 
at this time turned upon the question of formation of pus by the 
inflamed lining membrane of the vein or by a sort of endosmotic 
absorption of pus through the healthy walls of the vessels. 

Up to this time it was pretty generally believed that the phe- 

356 



PYsEMIA. 357 

noinena of pyaemia were produced by the presence of pus in the 
blood, by whatever route it may have obtained an entrance; but 
as early as 1822, Gaspard made experimental observations on ani- 
mals which led him to believe that the metastatic abscesses were 
due to the presence of putrid materials in the pus. Observations 
on the condition of the blood in pyaemia were numerous at this 
time, and the view was even advanced that inflammation of the 
blood itself, a haemitis, occurred. Rokitansky described a class 
of cases in which, apparently, a large number of pus-corpuscles 
were seen in the blood, but Virchow and Bennett recognized in 
these cases the affection which is now known as leukaemia. A 
great impetus was given to the advancement of the knowledge of 
this disease by the investigations of Virchow upon thrombosis and 
embolism. That which had been supposed to be pus found in the 
veins near an infected wound he showed was a collection of white 
corpuscles; that the masses which were mixed up with them were 
the remains of a softened thrombus; and that embolism resulted 
from detachment of the fragments of such a thrombus and their 
arrest in some distant capillary district. If a terminal arteriole 
was thus occluded, infarction took place, and a metastatic abscess 
might be the result of the irritating nature of the materials of 
which the embolus was composed. This explanation fully disposed 
of the old idea that pus penetrated the lumen of the vein by the 
rupture of an abscess. At that time a great distinction was made 
between " laudable " pus and "infected " or foul pus, and Virchow 
thought to emphasize his new views on the spreading of suppura- 
tion through the body by substituting the term " ichorrhaemia " 
(r//i)p, gore, corrupted matter) for "pyaemia." What this poison- 
ous substance was which produced such formidable complications 
had not yet been discovered, but light was soon thrown upon this 
point by the work of Pasteur on fermentation. From this time on 
the question of the bacterial origin of the disease gave rise to a vast 
amount of experimental investigation, which, however, did not 
succeed in clearing up this point until the methods of bacteriologi- 
cal study had become sufficiently perfected to give reliable results. 
A variety of experiments were made to determine whether the 
poisonous agent existed in the fluid or solid constituents of pus. 
Burden Sanderson, as early as 1865, injected the purulent fluid 
from an ankle-joint of a patient, ill with pyaemia, into the subcu- 
taneous tissue of animals, producing metastatic abscesses. In 
experiments made in 1872 he found in the pus artificially-produced 
bacilli and micrococci, to which he gave the name microzyme. 



35 8 SURGICAL PATHOLOGY AND THERAPEUTICS. 

Finally, a systematic study was made upon the microscopic 
appearance of organisms found in the pus of pyaemic patients. 
Doleris was one of the first to recognize in the lochia of infected 
puerperal patients what would probably now be called the "strep- 
tococcus," and the same organism was observed by Pasteur in fatal 
cases of puerperal pyaemia — the microbe en chapelet. He formu- 
lated the theory that the disease was due to this organism passing 
through the blood and lymph-channels to different parts of the 
body, thus producing metastatic inflammations. These organisms 
were reproduced by cultures taken from the blood and pus during 
life and after death. 

Koch injected fluid from putrefying flesh into the subcutaneous 
tissue of a rabbit and produced metastatic deposits; from the heart 
of this animal blood was taken and injected into another rabbit, 
and the disease was thus reproduced. The organisms observed were 
chain-like micrococci measuring about 0.25/* in diameter. These 
organisms were observed adherent in small clumps to the walls of 
capillaries of the kidney and other organs; each little mass of bac- 
teria enclosed several blood-corpuscles, and appeared to possess the 
peculiarity of causing the blood-corpuscles to adhere and form 
thrombi. If this is a characteristic of the streptococcus, which 
was probably the organism he saw, then an explanation is pre- 
sented of the origin of the most characteristic feature of pyaemia. 
Near the wound numbers of micrococci were found in the tissues 
and around the subcutaneous veins, and even in the walls of the 
veins, through which their passage could be demonstrated in many 
places. Owing to their peculiar adhesive properties, Koch found 
they did not remain long in the circulating blood, because they 
were soon deposited in the capillaries of the organs. No micro- 
cocci were found in the lymphatics. 

Ogston's work contains a number of interesting facts bearing 
upon pyaemia. His idea of a single poison for all forms of surgical 
fever is a simple and attractive one. He says: " Between a simple 
localized acute inflammation on the one hand and the severest case 
of pyaemia on the other there exists only a difference in degree, a 
difference in intensity." He shows that the swelling of joints, so 
characteristic a symptom of pyaemia, is produced by the effusion 
of serum, which, when examined, does not show the presence of 
micrococci, but these cocci are found in the coverings of the joint 
or in the synovial fringes around the cartilages, and, according to 
Ogston, the effusion takes place from a spot where a colony exists. 

Rosenbach thought that Ogston went too far in assuming that 



PYsEMIA. 359 

pysemia is purely a secondary affection. He examined 6 cases of 
pyaemia in man by making blood- and pus-cultures during life and 
inoculating animals with the organisms thus obtained. In 5 of 
these cases he found the streptococcus both in the blood and in the 
metastatic abscesses of the lungs. In 2 of these cases the staphylo- 
coccus was associated with the streptococcus. In 1 case he found 
the staphylococcus only, and this case recovered. As the result of 
his investigations he divides pyaemia into two varieties. The first 
is that which has already been described as suppurative fever; that 
is, a fever accompanying severe and extensive suppurations and fre- 
quently terminating fatally in the acute stage. Such cases are said 
to have died of exhaustion. In these cases he thinks the blood- 
poisoning is due to the presence of the staphylococcus, much as Og- 
ston describes, and that this kind of fever should be called "true 
pysemia." It may be said here that Heuter described this form of 
fever as "pyaemia simplex" in contradistinction to the embolic 
form, which he called "pysemia multiplex." The latter was Ro- 
senbach's second form of pysemia, or the " thrombo-embolic " form 
with metastasis, which, as he shows, may be quite independent of 
the condition of the wound and in active development, even after 
the wound has healed, and which is usually caused by the strepto- 
coccus. 

A good many observations have been made upon the bacteria 
of pysemia. Besser, for instance, examined the blood, pus, and 
parenchymatous fluids in 23 cases of pysemia. In 8 the staphylo- 
coccus was found; in 14, the streptococcus; and in 1 both kinds of 
cocci were seen. During life the cocci were found in the blood in 
11 out of 12 cases. Out of 46 cases, in all, collected by him, the 
staphylococcus was found in 22, the streptococcus in 21, and both 
were found in 3 cases. He concluded that there was no difference 
b>etween the cocci of pus and the cocci of pysemia. Pawlowsky 
examined 5 cases of pysemia in man, and found the staphylococcus 
in 4. In the fifth case, which had an unusual number of joint- 
complications, he found the streptococcus. He believed the 
staphylococcus is the usual cause of pysemia, and particularly in 
cases of abscess of the internal organs. 

Pawlowsky, perceiving that pure cultures of the pyogenic cocci 
when introduced into the organism disappeared rapidly, made sim- 
ultaneous injection of sterilized cinnabar particles and staphylococcus 
cultures into the circulation, and produced a typical pysemia with 
metastatic abscess. Injections of the coccus without the cinnabar 
were not sufficient to produce the disease. The particles of cin- 



360 SURGICAL PATHOLOGY AND THERAPEUTICS. 

nabar were supposed to have favored the formation of minute 
thrombi, impairing the local nutrition of the tissues and favoring 
impaction. Bonome also succeeded in getting metastatic abscesses 
by intravenous injection of fragments of sterilized pith with pure 
cultures of staphylococci. 

An important addition to the experimental investigation of 
pyaemia is that intended to throw light upon the origin of the 
nodular and ulcerative endocarditis found in this as well as other 
diseases. An acute endocarditis was produced by Wyssokowitch 
by introducing an instrument through the jugular vein and bruis- 
ing the valves, and subsequently by injecting bacteria of different 
kinds directly into the circulation. If the bacteria were injected 
into the connective tissue, or an interval of two days was allowed 
to pass after the lesion of the valves had been produced, or a very 
weak dose of bacteria was employed, the endocarditis did not take 
place. Ribbert succeeded in infecting the endocardium without 
previous injury by introducing fragments of potato with the cul- 
ture. These small particles enabled the bacteria to become, me- 
chanically, more easily arrested, and the injury inflicted upon the 
endothelia at the same time offered a soil more favorable to bacte- 
rial growth, owing to its impaired condition. 

The process by which the endocardial lesion appears to be formed 
in the human subject is as follows : The micrococci become attached 
either to some old lesion of the valve or to some point on the valve 
favorably situated to receive them, owing to the pressure of the 
blood-column against it when the valves are closed. A coagulation- 
necrosis of the inner wall of the vessel takes place at the point of 
attachment. A rough surface is thus presented to the blood-cur- 
rent, and numbers of white corpuscles or blood-plaques become 
attached to the little clump of micrococci and necrosed tissue, and 
a thrombus is thus formed. If the destruction of tissue is not 
great, the granulation tissue may cover in the micro-organisms 
and a nodular mass will be found in the valve; but if there has 
been extensive necrosis, when the protecting thrombus is swept 
away an ulceration will be observed in the wall of the valve. 
Baumgarten suggests that the tuberous form of endocarditis is 
produced by the staphylococcus, and the ulcerative form by the 
streptococcus. 

Having thus glanced over the most important experimental 
investigations in pyaemia, the reader is now prepared to form an 
opinion as to the nature of the micro-organisms and the route 
which they take in infecting the system. 



PYAEMIA, 361 

Both the staphylococcus and the streptococcus have been 
observed, and, although at one time it was supposed that the 
former was the principal agent in producing the disease, the data 
afforded by observers up to the present time do not permit one to 
decide in favor of either: so far as can be judged, therefore, it is 
probable that accidental anatomical and pathological conditions 
determine the question of a successful resistance on the part of 
the tissues, rather than the presence or the absence of either of 
the above varieties of micrococci. Enough is known of the vary- 
ing degree of virulence of pathogenic bacteria to enable one to 
realize that they may act very differently under varying conditions. 
This can easily be proved by clinical observation as well as by 
laboratory experiments. 

The route through which an infection of the system takes place 
from a wound is almost invariably the blood-vessels, although occa- 
sionally the infection may follow the lymphatic system. When the 
micrococci are not restrained in their growth in an infected wound, 
they soon reach the blood-vessels, and when they come in contact 
with the walls of a vein an inflammation is set up and thrombo- 
phlebitis results. As they reach the intima a disturbance of nutri- 
tion in the endothelium takes place, and rough places are thus 
formed on the inner surface of the vein. If, now, the descriptions 
of Osier and Zahn are recalled, it will be found that a number of 
leucocytes become adherent to such a spot and form a little mass 
attached to the inner wall, which mass after a while becomes more 
or less homogeneous, so that the individual corpuscles cannot be 
discerned. The white thrombus of Zahn is formed in this way, 
and it becomes the starting-point of a thrombosis which may so 
enlarge as completely to fill the lumen of the vein. The blood- 
plaques, as well as the leucocytes, will also be seen collecting 
about this rough spot, and aid in the process of coagulation. 
Such an event would seem to serve as a protection to shut off the 
damaged vein from the general circulation. The street has been 
closed for repairs, as it were, and doubtless in many a case such 
is the result of this effort on the part of nature. Unfortunately, 
the thrombus affords an unusually good soil for the micrococci, 
and an infection and puriform softening of the clot eventually take 
place. Inasmuch as thrombosis may occur throughout the extent 
of a large vessel — as, for instance, the femoral vein (Fig. 72) — a 
large mass of soft material, looking like blood-clot and pus mixed 
together, is contained inside the vessel, extending far beyond the 
limits of the wound and in more or less direct communication with 



362 SURGICAL PATHOLOGY AND THERAPEUTICS. 

the circulation. The mode of progress of the micrococci from the 
wound to the adjacent vessels seems merely to be a process of ger- 
mination and growth. It was at one time thought that they were 
transported into the thrombi already formed by the white corpus- 




Fig. 72. — Thrombus of Femoral Vein. 

cles, in the interior of which cells numbers of cocci are often found; 
but this theory has not been sustained. Thrombo-arteritis may also 
occur; that is, the micrococci may penetrate the arteries as well as 
the veins, but the denser walls and the more vigorous current do 
not favor development of thrombi; and when thrombi are found 
they do not, of course, spread to distant points, but fragments 
detached will remain in an adjacent capillary district. Fragments 
from the infected venous thrombi when detached are arrested in the 
capillary system of the lungs, where they form new foci of infec- 
tion, and favor the formation of a metastatic abscess (Fig. 27). Very 
small emboli may, however, pass through the lung capillaries, as 
the vessels are much larger than those of other capillary systems, 
and in this way the whole arterial system will be exposed to a sim- 
ilar infection. Cocci may also be found free in the circulation inde- 
pendent of emboli. Their direct penetration into the circulating 
blood is impeded by the thrombosis which occurs at the point of 
entrance in the vessel-wall. Small masses of micrococci may, how- 
ever, be detached before coagulation has taken place, and be swept 
off into the current. Single organisms are not likely to cause sup- 
puration, as the resistance of the tissues neutralizes their pathogenic 
action, and they quickly disappear from the circulation. 

The micrococci, when circulating through the blood, are lodged 
in and become attached to the endothelium of capillaries where the 
circulation is slow, or in the lumen of vessels with an anatomical 
arrangement favorable for a lodgment, as in the glomeruli of the 
kidney. Having reached a stationary point, they begin to grow 
either in the lumen or in the wall, and spread through a consider- 
able capillary district. A necrosis takes place around the mass of 
micrococci, and suppuration occurs at its border. As the cocci 



PYsEMIA. 363 

from the centre and the pus-cells from the periphery break into 
the necrosed tissue, it melts down and a miliary abscess is thus 
formed. If the bacterial growth is of slight intensity and is not 
extensive, necrosis will probably not occur, but suppuration may 
take place without it. Free micrococci may also become attached 
to the valves of the heart and to the veins by the blood-pressure 
forcing them into the soft endothelium while the valve is closed, 
causing nodular or ulcerating endocarditis. Fragments of emboli 
laden with micrococci are more likely to become attached in this 
way, as has already been shown experimentally. If the embolus 
is arrested in the terminal artery of an organ, a wedge-shaped 
infarction will result. The tissue, thus lowered in vitality, is soon 
invaded by the micrococci: leucocytes also wander in, a softening 
takes place, and there arises a wedge-shaped abscess situated near 
the surface of an organ. If the lodgment takes place in a tissue 
with free anastomosis, the cocci invade the intermediate tracts of 
tissue or parenchyma, or they may spread backward along the inner 
wall of the artery to a collateral branch, and may thus be carried to 
an adjacent capillary district; in this way a more or less diffused 
abscess will be formed. From the above examples it will readily 
be seen that the great variety of suppurations occurring in pyaemia 
can be accounted for by the spreading of micrococci from the origi- 
nal wound into different parts of the body. 

It will be perceived that the old idea that pyaemia was due to 
the presence of pus in the blood has been abandoned. It occa- 
sionally happens, however, that an abscess may be situated in the 
neighborhood of a large vein, and that perforation of the vessel- 
wall may take place, the abscess actually emptying itself into the 
cavity of the vessel. Schuh reports a case of a man suffering from 
an acute abscess behind the peritoneum. He was suddenly taken 
ill with symptoms of pyaemia, and died in two days. At the 
autopsy it was found that the abscess had broken into the ascend- 
ing cava and that metastatic abscesses existed in the lungs. 
Numerous balls of pus were found floating in the blood, and about 
two ounces of pus were collected from the blood-vessels. Gussen- 
bauer reports a number of such cases. 

Infection may also take place through the lymphatic system, 
although the chains of lymphatic glands offer a protection which 
is not found in the veins. Gussenbauer reports a case of gangrene 
of the lower extremities in which foul pus was found in the 
thoracic duct; Schuh records a case of lithotomy, with death three 
weeks after the operation, in which case the lymphatics over the 



364 SURGICAL PATHOLOGY AND THERAPEUTICS. 

sacrum and in the lumbar region were filled with purulent mate- 
rial, and the thoracic duct was distended to the size of a pigeon's 
egg with thin green pus which was found extending up to its 
opening in the vena cava. Pus may be found in the lymphatics 
of the broad ligaments of the uterus in cases of puerperal pyaemia. 
In such a class of cases the richness of the lymphatic connection 
and the direct communications with the venous system render a 
general infection more probable than in the case of suppuration in 
more superficial regions which have access only to the peripheral 
lymphatics on the surface of the body. 

All these forms of infection, which take their departure from a 
wound, have been called "types of extravascular infection," to 
distinguish them from a class of cases in which no wound is pres- 
ent; nevertheless, pyaemia exists. 

The cases of intravascular infection, or the so-called "sponta- 
neous pyaemias," have long been recognized, but their etiology 
has been but little understood. An otherwise healthy individual 
receives a trifling wound or catches cold, and after suffering from 
severe chills and fever, and perhaps swelling of the joints, dies, 
and metastatic deposits are found in the internal organs. A young 
man or a boy stays too long in the bath, and the next day he has a 
severe chill; symptoms of acute osteomyelitis of the femur 
develop, and he eventually dies of pyaemia. An interesting feat- 
ure of these cases is that they are frequently associated with acute 
ulcerative endocarditis. More will be said about their clinical 
features in discussing the symptomatology of pyaemia. 

How does infection take place in cases like these ? It has been 
pointed out that micrococci are found in the circulation even when 
no suppuration takes place. All that seems necessary is a lowering 
of the general tone of the system or the existence of some weak or 
diseased spot, in order that these organisms may break down the bar- 
riers which the normal tissues afford. Under such conditions there 
may arise a marked disturbance of function or circulation of an 
organ, as the kidney, perhaps from getting chilled, or an inflamma- 
tion may occur which will favor the localization of micrococci in 
that neighborhood, and a perinephritic abscess may be the result. 
A starting-point is thus established from which an extensive infec- 
tion of the system may occur. The changes in the nutrition of a 
rapidly-growing long bone, and its anatomical peculiarities, account 
for the fact that such tissue is a favorite seat of infective inflamma- 
tion. The rich anastomosis in the medullary cavity favors the accu- 
mulation of micrococci in a given capillary network. A rapid 



PYsEMIA. 365 

multiplication of the organism occurs: the vessel endothelium is 
first attacked, and then the intravascular tissues, and there is soon 
a considerable space undergoing necrosis and forming the central 
point of an acute suppurative inflammation. There are cases, 
however, in which no preliminary abscess is formed. The attack 
may be accompanied with no characteristic symptoms of local dis- 
ease, yet an autopsy will show metastatic abscesses in the inter- 
nal organs. In these cases marked evidences of ulcerative endo- 
carditis are pretty sure to be found, and it is supposed that the 
micrococci have obtained a lodgment in the valves of the heart. 
According to Osier, the number of primary cases of ulcerative 
endocarditis is limited, this lesion of the heart being more fre- 
quently associated with some other affection, even with such a 
disease as pneumonia. Pneumococci have been found in such 
cases. 

In pre-antiseptic days, when pyaemia was a much commoner 
disease in hospitals than it is now, it was thought that certain 
seasons of the year were favorable for epidemics of the disease. 
The writer has observed such an epidemic. Having had one or 
two deaths from pyaemia in his hospital wards, attention was given 
to the search for a local cause. To his surprise, he learned that 
a neighboring lying-in hospital had been closed on account of a 
similar "epidemic," and that several cases of puerperal pyaemia 
had also occurred in a suburban hospital. It was at the time of the 
year, the early spring, when erysipelas and other traumatic infec- 
tive diseases have long been dreaded by the surgeon. In some of 
these affections, as erysipelas, climatic influences seem to be an 
etiological factor, and the writer sees no reason to doubt the exist- 
ence of conditions in the atmosphere that are more favorable to 
the development of an unusual activity in the staphylococcus and 
streptococcus than at other times. So acute an observer as Sir 
James Simpson says: "There are epidemic states in which puer- 
peral and surgical fevers are frightfully common. Some localities 
and towns are far more frequently their seat than others." The 
enthusiasm for antisepsis should not allow the surgeon to forget the 
teachings of an earlier school, founded as they were on abundant 
experience. 

In a report made to the Pathological Society of London the 
statement is made that during ten years (1869 to 1878), within 
which period all cases of pyaemia in the London hospitals were 
recorded, the mortality of 1874 and 1875 was decidedly in excess 
of that of other years. These two years were noted for their marked 



366 SURGICAL PATHOLOGY AND THERAPEUTICS. 

meteorological conditions. In 1874 there was a remarkable defi- 
ciency of rain during the whole year. On the contrary, 1875 was 
characterized by its excessive rainfall. The most fatal months 
during this series of years were February and March. 

As to the influence of age and sex, it may be said that children 
and old men, and women at all times of life, are less frequently 
affected than men in the prime of life. This immunity is perhaps 
partly due to less exposure to traumatism, but so far as children 
are concerned this is probably not the reason. Wounds in children 
usually heal rapidly, the reparative process is more active, and it 
effects more perfect results than in maturer years. The blood and 
tissues of young children are, as a rule, purer and healthier, and 
the resisting power against infection is consequently greater. In 
the adult there is present all the ailments due to advancing years, 
which ailments handicap him in the struggle for life; and in cer- 
tain conditions of the system, such as alcoholism and diabetes, 
there exist conditions peculiarly susceptible to traumatic influ- 
ences. Pyaemia does occasionally occur in infancy: Savory 
reports cases in children ten months old, and one even as young 
as four days old. 

Among the kind of wounds which predispose to metastatic 
inflammation may be mentioned contused wounds, wounds of 
joints, compound fractures (supposed to favor pyaemia by fat-em- 
bolism), particularly fractures of the head, osteomyelitis, injuries 
of the veins or of the vascular regions, and wounds received 
in war or by individuals in an enfeebled condition. 

The disease usually makes its appearance about ten days after 
the injury — that is, at the height of the suppurative process — but 
it may begin at any time during the suppurative process. 

The most prominent of the symptoms of pycemia is the chill. 
This chill, however, may not accompany the first onset of fever, 
which is usually severe. At other times the chill may be the only 
symptom which first arouses the surgeon's suspicion, for the febrile 
disturbance may be slight or may be of a degree which has existed 
for some time; as, for instance, in a case of suppurative fever. An 
examination of the wound may reveal local infection and symptoms 
of infective inflammation. The lips of the wound are, in this case, 
red and swollen, and the interior of the wound may have a discol- 
ored or grayish, sloughing appearance, but, even though the wound 
be far advanced in the process of repair, a typical pyaemia may 
develop itself: indeed, some cases have been reported where the 
disease first made itself manifest after the wound had actually 



PYsEMIA. 367 

healed. In such cases the wound is probably situated near some 
rich venous anastomosis, as the hemorrhoidal veins or the sinuses, 
in which thrombi are readily formed. The chill may be either a 
slight shivering or of the severest type, followed by profuse per- 
spiration and considerable exhaustion. Usually after the chill is 
over the patient appears very much as before. There is no men- 
tal disturbance, although there may be at the same time consider- 
able fever. Ordinarily the surgeon does not observe a second chill 
until the following day; although Billroth, who has made a special 
study of the chills of pyaemia, states that as many as three chills 
may occur in the course of a single day. He also noticed that 
chills were less likely to occur during the evening and night than 
in the morning or afternoon. He lays special stress upon the 
marked difference between septicaemia and pyaemia so far as this 
symptom is concerned, as in the former disease, except perhaps at 
the onset, chills are never seen. The explanation of the chill is 
to be found probably in the existence of multiple suppurations 
throughout the body. The surgeon is aware that when in the 
course of an acute inflammation, as in cellulitis, a chill occurs, 
there is every reason to expect the appearance of pus. In the 
chapter on Fevers the writer endeavored to explain the cause of a 
chill and its relation to sudden elevations of temperature. With 
the formation of each new metastatic abscess there is probably a 
liberation of fresh pyrogenous material, which may have a more 
or less specific action on the blood and tissues, or possibly the 
nerves controlling heat-regulation, thus producing this special 
form of disturbance. 

A no less striking peculiarity of pyaemia are the variations of 
temperature. Billroth, who made a careful study of fever-curves in 
various fevers, first called attention to the curve of pyaemia. Heu- 
ter, who has also studied this question, speaks of the pyaemic curve 
as most characteristic. 

The fever-curve which pyaemia most nearly approaches is that 
of intermittent fever, but it varies from the latter in lacking regu- 
larity of change. It differs from all fevers in not having a regular 
evening exacerbation and morning remission, although this may 
occur. Heuter describes it as an "irregular intermittent type" 
(Fig. 73). Its irregularities are certainly great. The usual course 
of events is as follows : There is, at the beginning, usually a sharp 
rise, which may reach almost the highest point of the curve. If 
the temperature is already high at the time of the appearance of 
the disease, there will be a sharp rise to mark its onset. There will 



3 68 



SURGICAL PATHOLOGY AND THERAPEUTICS. 



be a period of pyrexia of longer or shorter duration, and then a 
fall, but not to the normal line, followed by a succession of similar 
exacerbations. During these periods of high fever the temperature 
remains at no fixed point, but there will be constant variation of 



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Fig. 73. — Pyaemia. 



fractional portions of a degree. These variations may occur almost 
hourly, so that it is necessary to take thermometric observations 
very frequently. It is customary, when the existence of pyaemia 
is suspected, to take a record every two hours, which is pretty sure 
to bring out varying undulations in the fever-curve. At the same 
time the daily record of temperature carried through the period of 
the disease shows also the greatest irregularities. In general it 
might be said that the curve of pyaemia consists of an irregular 
series of sharp rises- and falls, with an intervening zigzag outline 
to the curve. During all this time the normal line is not reached, 
yet in exceptional cases the temperature may return to normal, and 
may remain there for a day or two. Occasionally there has been 
observed a sharp rise post-mortem. The reasons for these remark- 
able changes are naturally to be sought for in the diverse patholog- 
ical appearances which are found at the autopsy. There may not 
always be an abscess to account for each chill or a chill to corre- 
spond to each abscess. Individual susceptibilities doubtless play 
an important role in the development of this symptom, but the 
multiple foci of embolism, infective inflammation, and suppura- 
tion, some visible and some almost imperceptible, amply account 
for the greatest irregularities in the fever-curve. 

After the first febrile phenomena have abated somewhat symp- 
toms of respiratory disturbance usually show themselves. A number 
of small metastatic abscesses may exist without indicating their 



PYsEMIA. 369 

presence by any symptom, but if they are superficial and are situ- 
ated near the pleural surface, the patient will generally complain 
of a sense of oppression and pain at that spot. Symptoms of 
pleurisy will develop, and auscultation may later reveal an effu- 
sion into the pleural cavity, and probably, also, the existence of 
pneumonia at the base of one or both lungs. With dyspnoea there 
will be cough with the expectoration of sputa, at first frothy and 
mucous, later rusty and perhaps purulent. In rare cases only 
haemoptysis occurs. Braidwood lays stress upon a peculiar "sweet- 
ish," u hay-like" "purulent" odor of the breath, of which he 
says : ' l This character of the breath in suppurative fever is very 
remarkable and of easy recognition." 

Metastatic abscesses of the liver cannot readily be recognized 
unless near the peritoneal covering, in which case localized peri- 
tonitis will be indicated by the presence of a sharp pain at that 
spot. Gussenbauer has recognized the presence of such lesions 
twice during life by auscultation, a slight crepitus being noticed. 

The discoloration of the skin that has gradually developed has 
now assumed a hue deep enough to be recognized as an icterus. 
It is described by Braidwood as " a yellowish tinge intermixed with 
the dull leaden or ashy color which accompanies wasting disease. ' * 
Its origin is not probably due to metastatic inflammation of the 
liver, which frequently is absent, but is either haematogenous or is 
caused by the presence of micrococcus growths in the capillaries of 
the skin. The facial expression, though not specially characteristic 
of the disease, is different from that of septicaemia. The marked 
emaciation which has already set in gives the eyes a hollow, sunken 
look. At the same time they show by their anxious expression that 
the intelligence is as keen as ever, and it may remain so until the 
final stages of the disease. The dryness of the skin occurring with 
the initial rise of temperature will be followed by profuse perspira- 
tion, a marked symptom as the disease progresses, appearing inde- 
pendently of the chill as well as immediately after it. 

Later in the course of the disease erythematous patches are 
seen, or there is a scarlet rash extending over the greater portion 
of the body. This rash assumes in pyaemia a most markedly papu- 
lar or even pustular form, and it is undoubtedly due to colonization 
of micrococci in the upper layers of the skin. Toward the end 
purpura spots are seen, and the pustules may coalesce and give rise 
to foul discharges, or vesicles filled with puriform fluid develop. 

There is not found so marked a disturbance of the digestive 
organs as in septicaemia. At first the bowels may be constipated. 

24 



370 SURGICAL PATHOLOGY AND THERAPEUTICS. 

The tongue is furred, the thirst is great, and, as the fatal issue 
approaches, the tongue becomes dry and brown and is coated at 
last with a heavy crust, while the gums and teeth are covered with 
sordes. Occasionally foul and bloody stools occur, but diarrhoea is 
a more characteristic symptom of septicaemia. 

Another marked symptom of pyaemia that develops itself as the 
disease progresses is general hypercesthesia. The patient complains 
of a sharp pain, first at one point, then at another. Many of these 
pains are undoubtedly due to metastatic inflammation, but the gen- 
eral tenderness which manifests itself on the surface of the body 
cannot be explained in this way. Such patients are extremely dif- 
ficult to handle or to move about in bed, and if, in addition, there 
is a severe wound or a compound fracture of the bone, the situation 
is extremely trying and painful for the nurse as well as for the 
patient. 

Where so much suppuration is going on one would naturally 
expect enlargement of the glands of the lymphatic system, and 
with them the spleen; but there is not found that pulpy softening 
of the spleen which is characteristic of septicaemia. Metastatic 
abscesses and infarctions may occur in this organ, as elsewhere, 
in which case there will be an enlargement that can be made out 
by percussion. 

As an indication of the state of the kidneys the condition of the 
tirine rarely affords much information. It will, of course, be some- 
what scanty and high-colored, particularly at first, and urates may 
be deposited in excess. A considerable amount of albuminuria 
with fibrinous casts would indicate a hyperaemia of these organs, 
possibly due to the ' presence of metastatic deposits, but possibly 
also to the febrile disturbance only. Pus-corpuscles are occasion- 
ally seen, and at times also bacteria in considerable quantities, due 
to the effort on the part of the system at elimination of the poison. 
Hofmeister has accounted for the presence of peptone, which is 
found in this as well as in certain other diseases, by showing that 
the active leucocytes in pus possess the power to retain peptone, 
so that the amount of it can greatly be increased. He regards, 
therefore, the presence of this substance in the urine as an indica- 
tion of the breaking down of pus-corpuscles in the body. Haema- 
turia has occasionally been noticed, but it is an extremely rare 
symptom. 

Not only are there complications in the internal organs during 
pyaemia, but on the surface of the body there is also much to 
occupy the attention of the surgeon. Among the most important 



PYjEMIA. 371 

of the complications are those found in joints. Early in the dis- 
ease the surgeon may have complaints of pain in the knee or in 
the shoulder-joints, and an examination of the knee will enable 
the surgeon to detect readily the presence of an effusion. The 
surrounding tissues may also be swollen and inflamed for a con- 
siderable distance. An incision into such a joint may disclose 
the presence of turbid serum or pus, which may collect with great 
rapidity. The sterno-clavicular articulation is often affected, but 
all joints, small as w r ell as large, are liable to be the seat of inflam- 
mation. 

Phlegmonous inflammations are also seen, but they more fre- 
quently accompany puerperal pyaemia. The surrounding tissues 
are cedematous and the muscles are of a brawny-red color. Meta- 
static inflammations of bones are not likely to occur, but in acute 
osteomyelitis of long bones accompanying some forms of ' ' sponta- 
neous pyaemia ' ' there are signs of most acute and extensive inflam- 
mation, accompanied by severe pain. The inflammation of joints 
may, however, be accompanied by inflammation, and even by sup- 
puration, of the adjacent bones. In amputation-stumps the signs 
of bone-inflammation are often present. There is an increased dis- 
charge of foul pus, and an examination discloses the presence of a 
sequestrum and of a protruding mass of granulation tissue from 
the medullary cavity. At a later period "the medulla is found 
dead, blackened, and encysted, but within it is a putrid mass of 
bone debris and pus. A probe passes down the entire length of 
the shaft." 

If the blood be examined during life, there are found, in addi- 
tion to the presence of micrococci already mentioned, an increased 
number of white blood-corpuscles and blood-plaques. The red 
corpuscles are, however, diminished in number, and many of them 
have a crenated or shrunken appearance, which may account in a 
measure for the anaemic pallor of the patient. (See page 100.) 
Symptoms of heart-lesion are rarely noticed, although in those 
cases in which ulcerative endocarditis is a prominent feature paiu 
in the region of the heart is occasionally mentioned. 

The ptrfse is fairly strong, but is more rapid than usual; in the 
later stages of the disease its weakness and rapidity are, however, 
very marked. 

The prostration at this period becomes a striking feature, as is 
also the great emaciation, w r hich at times becomes extreme. All 
these symptoms will be aggravated greatly by secondary hemor- 
rhages, which are not infrequent, and which are usually hard to 



Z12 SURGICAL PATHOLOGY AND THERAPEUTICS. 

control, as they may be repeated even after the ligature of a large 
vessel. 

In the later stages of the disease the mind begins to fail, and 
there occurs for the first time delirium, which, as the end 
approaches, gives place to coma. The presence of paralysis, stra- 
bismus, sudden deafness, or priapism may point to the existence 
of metastatic meningeal inflammation. Subsultus tendinum will 
almost always be present. 

The usual duration of pyaemia is from ten to fifteen days. Bill- 
roth's tables give ten cases which lasted from ten to eighteen 
weeks. It is probable, he thinks, that the thrombi form in the 
second week, and are most dangerous from softening in the third 
and fourth weeks. The writer has seen a case which lasted nearly 
two months. 

The pyaemia which has just been described is that form in which 
the virus finds an entrance into the system through the surface of 
a wound. But it has long been recognised that pycemia may 
occur although no wound exists. 

The etiology of this form of pyaemia has already been discussed, 
and the reader is therefore aware that the micrococci can get into 
the system by means of an intravascular infection. It remains 
for the writer merely to mention some of the cases which belong 
in this category. The most striking, perhaps, of all, and the 
one which the surgeon is most likely to see, is the case of acute 
osteomyelitis, generally of the long bones. Such a case is always 
ushered in by a chill. Symptoms of the most acute inflammation 
soon show the origin of the fever, and when finally suppuration is 
established and the abscess breaks, great injury has been done to 
the bone. A pyaemic complication is not, therefore, to be wondered 
at when the severity of the affection is considered. 

A good many of the cases of ulcerative endocarditis belong in 
this category, as has been shown. In some the lesion seems to be 
the primary — that is, the point of entrance of the micrococci into 
the tissues; in others the endocarditis may be but one of a series 
of secondary changes starting from an inflamed lung or kidney or 
from a rheumatic joint. The symptoms will vary considerably 
according to the disease of which the embolism and metastasis are 
complications. In the cardiac group, or those which supervene 
usually in cases of chronic heart disease when weak spots in the 
shape of fibrous scars exist upon the valves, there will be symptoms 
of pain in the cardiac region and palpitation, with a sense of dis- 
tress, and auscultation will disclose a murmur. 



PYEMIA. 373 

In some cases cerebral symptoms seem to predominate from the 
beginning; suppurative meningitis may coexist with a patch of 
pneumonia at the apex of one lung and with endocarditis of the 
mitral valve. Different portions of the body have been examined 
carefully to find the door through which the virus has entered in 
these forms of obscure origin. The following case, occurring in 
the writer's practice, fairly illustrates the type of pyaemia that 
develops without a wound : 

E. L , a female thirty-four 3-ears of age, entered the medical wards of the 

hospital with pain in the right lumbar region, which pain had existed for six 
weeks and which was ushered in with a rigor. She had been in poor health 
during the winter, and had recently suffered from one or two epileptic seiz- 
ures. The signs of suppuration growing more marked and pus appearing in 
the urine, a diagnosis of perinephritic abscess was made, and, as her condi- 
tion was grave, she was transferred to the writer's wards and the abscess 
was opened, ten ounces of pus being removed. Chills and increase of fever 
had developed before the operation. At the time of the evacuation of the 
pus a gelatin culture was taken, which in a day or two developed into the 
staphylococcus. No improvement followed ; the breathing became labored; 
involuntary dejections occurred ; the pulse ran up to 180, and the patient 
died on the fifth day after the operation. 

At the autopsy there was oedema of the lungs. Miliary abscesses were 
found on the surface of the heart and in the papillary muscles, and the edges 
of the aortic valves were thickened. There was hemorrhagic infarction of 
the spleen and acute purulent nephritis of the right kidney, and miliary 
abscesses in the central portion of the left kidney had occurred. A small 
metastatic abscess was found in the intestine, and one the size of a horse- 
chestnut was found in the liver. A microscopic section of one of the 
abscesses of the heart showed the typical microscopical appearances, a clump 
of micrococcus growth occupying the centre. At the demonstration before 
the class the original aureus culture was shown at the same time with the 
microscopical sections and the fresh organs in which metastasis had occurred. 

In puerperal pyaemia there is pretty much the same chain of 
events that occur in traumatic pyaemia. According to Baumgar- 
ten, the streptococcus is often found in secretions from the 
vagina, which seems to constitute a sort of lurking-place for it, and 
the lochia furnish a most admirable culture material. After par- 
turition the uterine contractions, the free flow of the lochia, and 
the rapid epithelial formations that cover the denuded surface do 
not give the cocci an opportunity to obtain an entrance. If, how- 
ever, the contractions are feeble and the lochia are retained, the 
sinuses are not securely closed, and if epithelial formation is pre- 
vented by placental remains, which are very favorable spots for 
bacterial development, or if the deeper layers of the uterine walls 
are torn, the door is at once opened to puerperal infection. The 



374 SURGICAL PATHOLOGY AND THERAPEUTICS. 

form of endometritis which results is usually a diphtheritic one, 
for the streptococcus has only a feeble peptonizing influence; but 
during a more prolonged stay in distant parts its capacity to cause 
inflammation may be strengthened, and it is then fully capable of 
causing suppuration. It may follow the route of the lymphatics 
or of the blood-vessels, causing parametritis, ulcerative endocar- 
ditis, and metastatic abscess in the various organs. Puerperal 
pyaemia is said by Billroth to be relatively less malignant than 
surgical pysemia. Of a series of 50 cases tabulated by him, 5 
recovered, and these 5 were all cases of puerperal pysemia. 

Surgical pysemia is sometimes divided into acute and chronic 
forms. The form usually described as chronic is that which has 
already been studied under the head of Suppurative Fever. The 
diseases are, however, of quite different character, presenting not 
only different causes, but different symptoms and pathological 
changes; they have only this in common: they are both compli- 
cations arising from a suppurating wound. 

As has been seen, pysemia may kill rapidly in a few days, or it 
may last weeks or even months. In the latter case the symptoms 
are not so pronounced as in the acute type: chills are less frequent, 
as metastatic inflammations are fewer in number. The chances for 
recovery is such cases are correspondingly greater. Such a case is 
the following, an example of true chronic pysemia: 

W. C , twenty-seven years old, a healthy brakeman, received a com- 
pound comminuted fracture of the left leg from a car- wheel. Amputation of 
the thigh was performed through the condyles . Extensive sloughing of the 
flaps followed, and on the seventh day a hemorrhage occurred from the popli- 
teal artery ; the vessel was secured in the wound, but four days later a second 
hemorrhage occurred, and the femoral was tied at the point of election. Three 
days later swelling and tenderness of the left parotid showed itself, and event- 
ually an abscess formed, which was opened. 

At this date there was also increased respiration with bloody sputa, and at 
times the patient became delirious. By this time the patient had become 
anaemic, emaciated, and greatly prostrated in strength. An offensive dis- 
charge oozed from the wound. The thigh was shrunken and the wounds 
were pale and blue. A day or two later a sharp pain in the right side at the 
level of the fifth rib ushered in a local pleurisy. 

Two slight hemorrhages occurred from the point of ligature of the femoral 
about a month after the patient's entrance to the hospital, and the artery was 
again tied higher up. He seemed now to be failing ; emaciation was extreme, 
and the sensitiveness of all parts of the body was so great that it was with 
difficulty that his wounds were dressed. Under stimulants and nourishment 
he rallied, however, and by the sixtieth day the temperature remained on 
the normal line for the first time. Pyrexia in a milder form returned later, 
and on the ninetieth day an abscess formed in the middle of the thigh, 



PYAEMIA. 375 

although the wounds by this time had nearly healed. After this no further 
suppuration occurred, and he was discharged from the hospital with two 
small granulating surfaces at the end of the stump four months from the time 
of entrance, the temperature having been normal for a week only previous to 
his departure. 

So much has already been said about the pathological changes 
seen in pyaemia that it would be difficult to give a detailed account 
of the post-mortem appearances without much repetition. 

Decomposition in the cadaver does not set in nearly so quickly 
as in septicaemia. The surface of the wound is of a blackish-green 
color like gangrenous tissue^ the granulations are smooth and glazed, 
and there is usually little discharge in the wound. Large arteries 
may be seen occasionally, partly open so far as their walls are con- 
cerned, but they are plugged by a protruding clot which is still 
firmly attached to them. Thrombo-phlebitis exists in veins lead- 
ing from or adjacent to the wound. The puriform softening may 
have broken down the entire thrombus, and nothing remains but a 
soft muddy puriform material, extending sometimes for a long dis- 
tance beyond all signs of local inflammation. 

Excellent examples of thrombosis can be seen in the sinuses 
after injuries to the bones of the cranium. An examination of the 
internal organs brings to light the presence chiefly of metastatic 
abscesses. But it must not be supposed that they are dotted about in 
the profusion seen in the beautiful anatomical plates of Cruveilhier 
and others. In the large proportion of a series of cases reported by 
a committee of the London Pathological Society a post-mortem 
examination showed the presence of abscesses in the lungs and 
such a swelling of the spleen and kidneys as one would expect to 
see in any severe febrile disturbance. The presence of abscesses 
of the lungs can easily be accounted for, the ramifications of the 
pulmonary artery being naturally the first lodging-place of a 
wandering embolus. They are more frequent in the lower lobe, 
as the branches of the artery are somewhat larger there. They are 
not usually of large size, but several may run together and form a 
cavity as large as a hen's &gg. Catarrhal pneumonia may surround 
them. Infarction may also occur. A serous effusion is often found 
in the pleural cavity; more rarely it is purulent. 

The liver is usually in a state of cloudy swelling. Occasionally 
it is the seat of abscesses, which arise from several sources. They 
may be the result of thrombosis of the pulmonary veins following 
abscesses in the lungs, or they may be dependent upon the soften- 
ing of thrombi in the portal system, or, finally, they may be caused 



37 6 SURGICAL PATHOLOGY AND THERAPEUTICS. 

by minute emboli which ha've passed the lungs. They are sup- 
posed to follow, frequently, injuries to the head, and they are not 
numerous, and frequently are quite superficial. Occasionally a 
single large abscess will be found in the liver. The liver is said to 
be, next to the lungs, the most frequent seat of metastatic deposits. 

The kidneys are often the seat of miliary abscesses or small 
emboli (Fig. 27). The metastatic deposits are more frequently 
seen in the cortical portion, for the reason, as already noted, that 
the Malpighian bodies are particularly favorable for the lodgment 
of masses of micrococci. On section, the organ appears swollen 
and cedematous. The metastatic abscess is the lesion most fre- 
quently seen, but infarction may be found also. 

Morbid lesions of the heart are not so frequent in the surgical 
forms of pyaemia as they are in the class of cases that have been 
described. The mitral or the aortic valve may be affected, but, 
according to Hutchinson, more frequently it is the mitral, and this 
author mentions two cases in which the lesion was recognized 
before death by a mitral murmur. The lesions consisted in nod- 
ular growths upon the valves, which subsequently break down 
and leave the so-called "ulcerations." This process may be so 
extensive sometimes as to leave an ulcer of considerable size; 
according to Osier, perforation of the septum has even occurred. 
Metastatic abscesses may also be found in the muscular substance 
of the organ. The existence of slight pericarditis may be indi- 
cated by the presence of an increased amount of fluid in the peri- 
cardium. 

The intestinal canal, as already seen, is not so likely to be 
affected in pysemia as in septicaemia, and frequently no patho- 
logical changes whatever are found. A miliary abscess may, how- 
ever, occasionally be found in the submucous tissue, and the latter 
membrane may occasionally also be affected and break down, thus 
forming ulcerations. The latter may appear as small ulcers pene- 
trating the mucous and vascular coats, and they are occasionally 
seen near the pyloric orifice of the stomach in puerperal cases. 
According to Braidwood, the large intestine appears to be more 
frequently affected, and the ulcers, when of any size, are situated 
with their long diameters across the axis of the canal. 

The brain may be passively hyperaemic, when the heart and 
lungs are affected, with some effusion in the ventricles. The pres- 
ence of metastatic abscesses is rare: when seen they are small and 
are in the cortical portion. One would more likely find patches of 
congestion in different portions of the brain, or suppurative meuin- 



PYsEMIA. 377 

gitis. Metastatic deposits have not been found in the spinal cord, 
perhaps because the lack of well-defined symptoms does not lead to 
an examination of that organ. 

Inflammation of the connective tissue with suppuration is occa- 
sionally seen. Gussenbauer has found it more frequent in puerpe- 
ral pyaemia. Infection may occur through the arterial system, or 
local metastasis may occur in the neighborhood of the wound, as 
in one of the cases first reported. 

Joint-inflammations are also supposed to be more frequent in 
puerperal pyaemia, but they are certainly a characteristic also of 
surgical forms of the disease. The knee and shoulder are the parts 
most frequently affected, but inflammation is often found in the 
wrist and in the sterno-clavicular and temporo-maxillary articula- 
tions. An inflammation of the latter joint might easily be mis- 
taken for suppurative parotitis. The condition found on opening 
the joint in the milder form of inflammation is congestion of the 
synovial membrane accompanied by a more or less abundant effu- 
sion of synovial fluid. Later, pus forms, ulceration of the cartilage 
takes place, and the joint may become completely disorganized. 
In other cases a large quantity of pus may form in a joint, and on 
washing it out only very slight traces of morbid action may be 
observed (Savory). When the joint-inflammation has been severe 
and acute in type the surrounding tissues are often extensively 
involved. It is in these cases that the muscles, when cut into, 
exhibit the brawny condition so often described. Metastatic 
abscesses are more often found in muscles of the extremities 
than in those of the breast. Purulent exudation is sometimes 
found even in the sheaths of the tendons. Bristowe mentions 
the presence of metastatic abscess in the tongue. Perhaps much 
of the hyperaesthesia complained of by pyaemic patients may be 
due to congestions or to inflammations in the soft parts, which at 
the autopsy escape notice. 

The bones are more frequently the seat of inflammation, from 
which pyaemic poisoning may originate, than the seat of secondary 
abscesses. The medullary tissues are so constituted, anatomically, 
as to favor absorption of the products of infective inflammation. 
The bones in the neighborhood of the wound are likely to show 
signs of periostitis and osteomyelitis in pyaemic cases. Metastatic 
abscesses are seen, however, in the diploe of the cranial bones. 

The parotid gland is not unfrequently the seat of metastatic 
abscess. A metastatic panophthalmitis is sometimes caused by an 
embolism of the retinal and choroidal vessels. Such an inflamma- 



37§ SURGICAL PATHOLOGY AND THERAPEUTICS. 

tion is of course very destructive, and the contents of the globe 
usually slough and escape. Gamgee has seen metastatic abscess 
three times in the prostate. Rarer seats of abscess are the thyroid 
gland, the mediastinum, the testicles, and the ovaries. 

The diagnosis of pyaemia is not difficult after the disease is 
well established, for the intermittent type of fever and the chill 
are sufficiently characteristic, particularly if there be a suppurating 
wound. The presence of mental disturbance with a sudden chill 
and fever, and the existence of sloughing tissue in the wound, 
would be suggestive of septicaemia. If there were considerable 
digestive disturbance coincident with a chill, the surgeon might 
suspect the approach of an attack of erysipelas. Emaciation, 
hyperaesthesia, diaphoresis, and great prostration are symptoms 
sufficiently characteristic to aid in establishing the diagnosis, which 
will be confirmed when the existence of a metastatic abscess has 
been established with certainty. 

Speaking of the prognosis of pyaemia, Savory graphically says: 
" Seldom giving any warning of its approach, it will at once con- 
vert a case which just before seemed full of promise into one past 
all hope of recovery ; for it cannot be denied that, with rare excep- 
tions, to pronounce a patient the subject of pyaemia is to say that 
he is a doomed man." Nevertheless, the number of cases of 
recovery that have been reported is a respectable one. In the first 
place, there is a relatively high percentage of cures in puerperal pyae- 
mia. In surgical pyaemia most writers report cases of cure. In one 
case an account has been given of the autopsy performed upon a man 
who had recovered from pyaemia the year before: the cicatrices of the 
metastatic abscesses were plainly visible in the internal organs. Ac- 
cording to Guerin, these patients do not long survive their recovery. 

The treatment of pyaemia is of course chiefly preventive. The 
results obtained by the introduction of the antiseptic treatment of 
wounds are probably more brilliant than those which the history 
of any other affection, medical or surgical, can show. 

When once the disease is established, it has been suggested that 
amputation of the injured limb, if the wound be in that region, 
would cut off the source of the poison. This expedient the writer 
tried in one case, but without success. At the autopsy it was 
shown that the puriform softening of the thrombus extended to 
Poupart's ligament. Still, a number of cases have been reported 
wherein pyaemia has been arrested by amputation. Ligature of 
the infected vein has been advised, and more recently opening the 
vein and removing the infected thrombus. 






PYAEMIA. 379 

The investigations of Macewen have given a strong impetus to this mode 
of dealing with the lateral and sigmoid sinuses in eases of infection following 
suppuration of the middle ear. As the result of this infection, thrombosis 
occurs not only in the sinuses mentioned, but the internal jugular vein, espe- 
cially its upper third, not infrequently also participates in the inflammatory 
action. When disintegration of the thrombus takes place systemic infection 
may occur, the emboli lodging themselves in the lungs principally, and occa- 
sionally in the liver and kidneys. If an extensive thrombosis has been set 
up in the sinus, a portion of it may be placed beyond the limits of the infected 
area, so that while the centre of the thrombus undergoes puriform softening, 
the extremities may still remain aseptic. As the result of this infection the 
w T all of the sinus may break down and pus may collect between the wall of 
the vessel and the bone. On opening the bone at the point of the sigmoid 
groove granulations are often seen covering the sinus, and often along with 
these there is an oozing of pus. 

If the vein-wall is still intact, it may be laid open, and the contents of 
the sinus may thus be exposed to view, when the disintegrating clot ' ' may 
be removed by the aid of a small spoon or gently washed out : the former is 
the safer." In manipulating the contents of the sinuses, especially when 
removing the thrombus from the side nearest the jugular bulb, care is neces- 
sary against admission of air, more especially if aseptic washings be em- 
ployed. Macewen does not recommend the ligature of a large sinus. Bal- 
lance and Horsley have, however, recommended the ligature of the internal 
jugular in addition to the curetting of the sinus, and this operation may be 
performed in cases where the infection has extended to this vein. If it is 
necessary to ligature the vein, it should be done before clearing out the sinus. 
It must not be forgotten, however, that the internal jugular is not the sole 
channel between the sigmoid sinus and the lungs. 

In the United States the operation of curetting the sinus has been per- 
formed successfully by Mixter. About an inch and a half of the sinus was 
exposed, and, as it showed no pulsation, it was incised and an inch and a 
half of softened thrombus was removed with an ordinary dressing-forceps. 
Jack has also performed this operation, without, however, succeeding in 
saving the patient. 

Macewen recommends that infective pustules on the face or lips should 
be excised and that the main veins should be tied. " In infective wounds of 
the orbital cavity, rather than permit the formation of infective thrombosis 
of the cavernous sinus, the serious question of extirpation of the eyeball 
and clearing out of the contents of the cavity may arise." 

The success of this method has been sufficiently great to author- 
ize its employment in other regions of the body, as, for instance, 
in the femoral vein. It is only radical measures like these that 
will offer any hope of relief after infective thrombosis has once 
been established. 

Complete disinfection of the wound should of course be attempted 
if putrefying discharges are retained, and its walls should be curet- 
ted thoroughly to remove the layer of germinating bacteria. Meta- 
static abscesses should promptly be opened and disinfected when 



380 SURGICAL PATHOLOGY AND THERAPEUTICS. 

possible; and if suppuration is established in a joint, it should not 
be allowed to go on without an attempt to arrest its progress by 
surgical interference. Incision and free douching with antiseptics 
are advised, and in cases of chronic character this procedure may 
be sufficiently successful to save life. 

The administration of antipyretics is not advisable, as most of 
them have a rather debilitating effect upon the heart. If any drug 
should be thought desirable to combat the fever, quinine is to be 
preferred. Alcohol is probably the surgeon's mainstay in the dis- 
ease, and it should be given freely even to patients who are not 
accustomed to its use. Their temperate habits will now stand them 
in good stead. The amount should be so adjusted as not to cause 
flushing of the face at any time. Easily-digested food of the most 
nutritious kind should be given with all the care that skilled nurs- 
ing can devote to its administration. 

The hygienic surroundings should of course be considered. If 
the patient is in a hospital, he may be moved into the open air for 
several hours a day if the disease is not running too acute a course 
or the exhaustion caused by the moving is not too great. If the 
case becomes chronic, a complete change of room and of clothing 
will often produce the same effect upon the course of the disease 
that a change of climate does to an invalid. 

The weakened condition of the blood should not be overlooked 
during convalescence. The administration of iron would probably 
be indicated to repair the damage done to the red blood-corpuscles. 
It is to be hoped, however, that few surgeons will ever see cases of 
pyaemia in the future. 



XVI. ERYSIPELAS. 

One of the most frequent of traumatic infective diseases, and 
one which antisepsis has not yet succeeded in banishing entirely 
from our hospitals, is erysipelas. It may be defined as an acute 
inflammation of the skin spreading along the surface, and rarely to 
the deeper parts, with a tendency to spontaneous recovery. It is 
accompanied by acute febrile disturbance; it may involve mucous 
membranes ; it may recur. The name is said to owe its origin to 
ipodpoz, red, and netta, skin. There is, however, no good Greek 
authority for the latter word. 'Epuaoc; and 7isAa<; are suggestive 
words, but have no meaning which would justify their use. 

The disease was known to the ancients, but reliable reports of 
epidemics date back not farther than the latter part of the 
eighteenth century. Erysipelatous angina was epidemic in Great 
Britain in 1777 and 1800, and extensive epidemics occurred also in 
that country in 1821 and in 1832; there was an epidemic in France 
in 1750. According to Tillmans, during 1843 the disease visited 
Scotland, Denmark, and Germany, and numerous American authori- 
ties bear testimony to the fact that it prevailed in America in 1842. 
Hall and Dexter give a description of ' ' erysipelatous fever " as it 
appeared in 1842-43 in the northern section of Vermont and New 
Hampshire. 

The accounts of these epidemics paint pictures of a much 
severer type of disease than the surgeon is accustomed to see to- 
day. The inflammation began frequently in the throat. In Indi- 
ana the tongue was noticed to become very much swollen, assum- 
ing a blackish-brown color, and deglutition was almost impossible. 
In New England the phlegmonous form was common. One prac- 
titioner writes: " The whole surface, under the pectoral muscle 
extending to the axilla, frequently under the latissimus dorsi run- 
ning up under the muscles of the shoulder, is, in not a few cases, 
one extensive abscess." In many cases the muscles and bones 
were involved, and the discharges were said to be so acrid that the 
hardest steel was "directly penetrated by it as by nitric acid," and 
the instruments used in opening an abscess were found, after being 
laid aside for a few hours, to be entirely unfit for further use. The 
epidemic prevailed in the greater portion of the Northern States, 

381 



382 SURGICAL PATHOLOGY AND THERAPEUTICS. 

and large numbers of lives were sacrificed. This appears to have 
been the last expiring effort of the disease as an epidemic type, for 
since that time no such accounts are preserved in literature, and 
during the writer's own experience the disease in that form has 
practically been unknown. 

The origin of the virus of erysipelas has always been a matter 
of much dispute, many having thought that no specific poison 
existed, but that the disease was caused by exposure to cold or by 
meteorological influences. The early experiments made to test the 
possibility of transmitting the virus to animals, and of thus prov- 
ing the inoculability of the disease, did not meet with such success 
as to settle the question definitely. Prominent among these experi- 
ments were those of Tillmans, who inoculated rabbits and dogs 
with virus taken from the large vesicles which form upon the dis- 
eased skin, and also with blood, lymph, and pus. Out of 25 experi- 
ments conducted in this manner, 5 only were successful. In these 
5 cases the disease was subsequently transmitted to other animals. 
Tillmans concludes that the disease is only mildly contagious, and 
this was also the opinion of other observers. 

Fehleisen, who was one of the first to isolate the streptococcus 
of erysipelas, succeeded not only in transmitting the disease to ani- 
mals, but also from man to man. The human inoculations were 
justified by being used for the purpose of curing chronic forms of 
ulceration of the skin, such as lupus or rodent ulcer and also sar- 
coma. Of seven persons thus inoculated, six developed erysipelas ; 
the single failure was probably due to the fact that the patient 
inoculated had passed through an attack of the disease some three 
months previously, and was therefore supposed to be protected 
from a second attack. The period of incubation was found to be 
from fifteen to sixty-one hours. The coccus was found in the 
lymphatic vessels of the skin and in the lymph-spaces, and when 
the culture was pure it never produced suppuration. Fehleisen 
concludes from his observations that the erysipelas coccus is a 
specific microbe which will always reproduce the disease when 
inoculated even in the smallest quantities, differing thus from the 
staphylococcus, which must be administered in a sufficiently large 
dose. These experiments upon man were based upon the experience 
that an attack of erysipelas often exerted a curative effect, but in 
the cases mentioned the inoculation failed to cure the malignant 
growths. Finally, a death having occurred from erysipelas in the 
hands of imitators of this method, further experimentation in this 
line was very properly abandoned. 



ERYSIPELAS. 383 

The bacteriological studies of Koch, Rosenbach, and other 
observers fully confirmed those of Fehleisen as to the nature of the 
organism which is the cause of erysipelas. The single cocci are 
from 0.3// to 0.4// in diameter. They grow in serpentine chains, 
the links of the chains forming pairs of cocci, as in most forms of 
streptococci. When each coccus is about to divide it becomes 
larger and oval, and two cocci result from the fission of the old 
one. The organism is readily stained with the usual aniline 
reagents. 

The question of the identity of the erysipelas coccus with the 
streptococcus pyogenes has frequently been raised, and authorities 
are not yet entirely agreed upon this point. The coccus of erysip- 
elas is somewhat larger than the streptococcus. The culture on the 
surface of agar appears as a very delicate grayish-white film com- 
posed of great numbers of minute colonies closely crowded together. 
When the gelatin is inoculated fine white granular masses form 
along the line of puncture, but at the surface there is usually not 
much growth. The culture shows after twenty-four hours, and 
reaches its full development in four days. It does not have a sol- 
vent action upon the gelatin. The cultures die out at the end of 
four months. 

Baumgarten thinks that the erysipelas coccus and the streptococ- 
cus show different degrees of activity in the same species — that they 
are the same organism, which under different external conditions 
act differently. The organism when situated in the superficial firm 
layers of the skin acts with less virulence, causing sero-cellular or 
fibrinous exudation, while in the loose structures of the subcu- 
taneous tissues it acts more vigorously, causing suppuration. Many 
modern observers concede that the erysipelas coccus causes not only 
erysipelas, but also abscess, but many others believe that when sup- 
puration occurs, it is due to pyogenic cocci which have become 
inoculated secondarily, and that suppuration is therefore merely a 
complication of the disease. Experimental inoculation with ery- 
sipelas cocci has, in the hands of one observer, always produced 
erysipelas, while inoculations with the streptococcus produced 
phlegmonous inflammation. 

If the organisms are situated in the skin the inflammation will 
be erysipelatous, but if in the deeper tissues it will be phlegmon- 
ous. Tillmans would group all progressive types of inflammation 
in the same class. Such a classification would place not only cel- 
lulitis, but also lymphangitis, malignant oedema, and even fulmi- 
nating gangrene, in the same group with erysipelas ; but our pres- 



384 SURGICAL PATHOLOGY AND THERAPEUTICS. 

ent knowledge of the bacteriology of these affections would hardly 
authorize such a wholesale grouping. 

The cocci are found in the capillary lymphatics of the skin and in 
the lymph-spaces chiefly, but they are sometimes also seen in the 
capillary blood-vessels and in the small veins. They may be 
found even beyond the lines of the inflammation in parts as yet 
unchanged. Near the red border the growth of organisms is most 
active. The lymphatics are so crowded with them that leucocytes 
are hard to find. Chains of cocci may be seen at this point in the 
adjacent connective tissue, and here also will be observed the signs 
of active inflammation as indicated by hypersemia of the vessels, 
emigration of leucocytes, and swelling of the fibres of the connec- 
tive tissue. According to Baumgarten, the cocci lie between the 
leucocytes in the lymphatics, but in the tissues they are occasion- 
ally found in the cells. Nearer the centre of the inflamed parts, 
where the process has been going on longer, the infiltration is 
greater, but the cocci have, according to Baumgarten, disappeared. 
They are found in small numbers only in the vesicles. Baumgar- 
ten does not agree with Metschnikoff that the disappearance of the 
cocci is due to phagocytes. The cell-exudation does not take place 
until after the coccus growth has reached its height, and only a few 
cocci are found in the cells. The cocci do not spread through the 
body in the vascular circuit, although they may occasionally be 
found in the blood-vessels at a distance from the inflammation. 
The constitutional disturbance accompanying erysipelatous inflam- 
mation is undoubtedly due to their presence in the circulation or 
to the presence of ptomaines. The appearance of the disease at a 
point distant from the seat of the inoculation is clinical proof that 
the virus may be transmitted through the circulation. 

If the erysipelas cocci are identical with some of the chain-like 
cocci found in decomposing substances, this accounts for the fact 
that the disease may be acquired both by contagion and by mias- 
matic infection, as in epidemics; also for its occurrence at certain 
seasons of the year; and also for Billroth' s clinical observations 
that it is in wounds chiefly discharging decomposing secretion 
mixed with blood that erysipelas is most likely to occur. 

The most frequent point of entrance of the virus is through the 
wound, and from this point it spreads rapidly through the lymph- 
capillaries of the surrounding skin. In the so-called "cases of 
idiopathic erysipelas" the disease was supposed to develop itself 
quite independently of any trauma, but even in these cases it is not 
difficult to imagine that some minute wound, abrasion, or diseased 



ER YSIPELAS. 385 

spot 011 the surface of the skin may offer a suitable soil for the 
inoculation of the microbe. The routes taken by the pyogenic 
cocci in producing boils and carbuncles could readily be followed 
bv the erysipelas coccus. The disease does not always manifest 
itself at the point of entrance, but it may appear first at some dis- 
tant portion of the body, thus necessitating transmission of the 
organism through the circulation. It is possible that the lungs or 
the digestive tract may allow the passage of the microbe, and that 
the infection of a certain locality may be through the circulation 
instead of through the integuments. Whether a slight trauma 
of the mucous membrane is necessary for such invasion cannot 
easily be decided. It is, however, highly probable that healthy 
skin offers a sure protection against infection. 

The clinical evidence of the contagiousness of erysipelas is 
abundant. Fortunately, the material to be obtained on this point 
belongs to a period that has already passed. The occurrence of 
erysipelas following vaccination has at certain periods become so 
serious and so frequent a complication that the operation has for 
the time being been abandoned. This was the case in Boston in 
the winter and spring of 1850. In the records of the Boston 
Society for Medical Improvement, Morland, the secretary states: 

" Of late, however, cases have multiplied to such an extent, and the result 
has been so often fatal, that many members of the society have refused to 
vaccinate except when it has been absolutely necessary, and have almost 
wholly given up revaccination." 

Cabot reported the case of a gentleman sixty-nine years of age who was 
revaccinated, and at the end of a week phlegmonous erysipelas developed. 
The disease invaded the chest and the right arm as well as the left. The sup- 
puration was severe about the left shoulder, and the pectoral muscle was thus 
separated from the parietes of the thorax. Numerous openings were made 
about the elbow and shoulder for the discharge of pus. The patient was con- 
fined to his bed for two months. Bigelow reported a case of a healthy child 
five months old. On the eighth day there was taken from the vesicle matter 
with which he vaccinated three other children. On the next day the arm 
became erysipelatous, and the child died in a few days. All the patients vac- 
cinated from this child had typical vesicles and no anomalous symptoms. 
Bigelow regarded this as evidence conclusive against the transmission of 
erysipelas by vaccination. 

Tillmans, however, has no doubt that in many cases the vac- 
cine lymph has conveyed the virus of erysipelas. Barbieri vac- 
cinated forty-nine children with virus from a child who had ery- 
sipelas at a distance from the vesicle, without his knowledge, and, 
out of twenty-one children who had a vesicle, twelve contracted 
erysipelas and four died. This, however, does not prove that the 

25 



386 SURGICAL PATHOLOGY AXD THERAPEUTICS. 

vaccine lymph necessarily contained erysipelas poison, for the 
points may have become infected after having received the lvmph. 
Whether such a mode of transmission of erysipelas cocci is pos- 
sible could be determined only by a series of experiments in 
which all the conditions considered necessary for a reliable bac- 
teriological experiment had been complied with. There is little 
doubt, however, that inoculation might take place by unclean 
instruments, so that the pustule might become infected bv the 
virus emanating from a concurrent epidemic of the disease. 

The close relationship of erysipelas and puerperal fever has long 
been well recognized, and it is of especial interest in view of the 
fact, which is now known, that both these diseases are caused bv 
the streptococcus type of bacteria. Dr. O. W. Holmes, in a paper 
on the contagiousness of puerperal fever, reports an epidemic of 
that disease in the practice of a physician who made the autopsy 
in a case of oedema and gangrene of the thigh, and received an 
injury to his ringer which confined him to the house. Several 
cases of erysipelas occurred in the house where the autopsy was 
performed, and two of the nurses who cared for the puerperal cases 
died of erysipelas. Stille reports the experience of a Philadelphia 
physician who had 95 cases of puerperal fever in rapid succession, 
and of the children born in these cases no less than 15 died of 
erysipelas. But perhaps the most striking example of the close 
relationship of the two diseases is the following: There was an 
epidemic of puerperal fever in the Hopital St. Louis in January 
and Februarv, 1861: no new cases could be admitted. The puer- 
peral patients already in the hospital were transferred to a derrna- 
tological ward, while the patients with disease of the skin — thirty- 
two in number — were placed in the puerperal ward, whereupon an 
epidemic of erysipelas broke out among those patients, and several 
of them died. 

The question of the transmission of the disease from case to case 
has been much discussed, and, although the contagiousness of ery- 
sipelas has been recognized by many writers, still there are high 
authorities to-day who are not prepared to accept this view. Gross 
says: "The question of the contagiousness of this disease is not 
yet fully settled. Much may be said both against and in favor of 
this view. My own opinion, founded on considerable experience, 
is that the affection at times possesses such a character. " Stille 
says: "But direct clinical proof is also abundant that erysipelas 
itself is communicable bv contagion." The occurrence of several 
cases of the disease in a certain locality or in a hospital ward is not 



ERYSIPELAS. 387 

necessarily evidence of its contagiousness, for such a concurrence 
of events may be due to a common cause from which each case has 
taken its origin. But when a case is brought to a given point and 
it becomes the focus of an epidemic, the evidence in favor of con- 
tagion is much more conclusive, as the following examples show: 

In 1852 a man arrived in Platte county, Missouri, with facial erysipelas. 
The farmer who nursed him fell ill with the disease; a second farmer who 
nursed and slept with these two individuals was taken with erysipelas; sub- 
sequently six other persons who helped to nurse these cases were themselves 
attacked. No other cases occurred in the neighborhood (Stille). 

A young man visited an intern of the Lariboisiere in Paris who was ill 
with erysipelas ; on returning to his home in Guise he was taken with the 
disease, and died in thirteen da3 r s. His servant had erysipelas. A relative, 
who visited him from a distance, two days after his return home was taken 
ill. His wife also had erysipelas, and likewise three neighbors who visited 
them during their illness. A relative of the latter who came from a neigh- 
boring village to see them was the next victim; also three Sisters of Charity 
who nursed them, and who, on their return to the convent, infected several 
other sisters. The physician who attended these cases died of erysipelas, as 
did also his daughter. Previous to this time there had been no cases of ery- 
sipelas in any of these localities. 

It was the common experience of many a hospital surgeon, in 
times past, that a single case of the disease, allowed to remain in 
the open ward of a hospital, has given rise to no other cases. Such 
facts as these have caused many to doubt the theory of contagion, 
and it is highly probable that the average case of erysipelas is but 
feebly contagious. There are, however, undoubtedly cases which 
are contagious in the highest degree, particularly when gangrene 
or phlegmonous inflammations occur as complications. In former 
times diseases of this type could be followed from bed to bed, and 
there often existed a certain ward or some bed where the occupants 
were generally expected to have the disease. 

At the present time, when antiseptic dressings isolate a patient 
so much more effectually from his neighbors, it is probable that a 
case allowed to remain in a ward where other wounds existed 
might not communicate the disease. The more complete know- 
ledge of the virus of erysipelas has, however, given rise to greater 
care to bring about isolation. The old view that the disease may 
be caused by exposure to cold or by climatic conditions is generally 
discarded, although these conditions may undoubtedly act as pre- 
disposing causes. The season of the year and the state of the 
atmosphere may at times be more favorable to the development 
of the erysipelas cocci than at others, and the greater activity of 
these organisms at certain periods is thus accounted for. Certain 



388 SURGICAL PATHOLOGY AND THERAPEUTICS. 

it is that in the winter and early spring months this disease is more 
likely to be epidemic than at other seasons. The presence of de- 
composing materials provides a soil favorable for the development 
of the cocci, as has already been seen. The presence of any decay- 
ing substance, imperfect drainage, and bad hygienic surroundings 
are therefore to be regarded as predisposing causes of the disease. 

So far as age is concerned, it may be said that in children the 
disease is comparatively rare. Erysipelas neonatorum is, however, 
frequently epidemic in badly-arranged lying-in hospitals, and it is 
usually associated with puerperal fever. This disease does not 
appear frequently during old age. Whether certain constitutional 
affections, such as scurvy, alcoholism, diabetes, and tuberculosis, 
predispose to erysipelas is still a doubtful question. Some individ- 
uals have frequent attacks of the disease, and they are supposed to 
have an hereditary disposition. The idea that persons with a 
lymphatic constitution, or, as Heuter suggests, those with large 
lymph-capillaries and broad lymph-spaces in the skin, are more 
susceptible, is certainly suggestive. 

Attention must now be turned to the symptoms of erysipelas. 
When in the course of the healing of a wound there is found a 
sudden attack of febrile disturbance, ushered in usually with a 
chill, which has been ascribed by the friends or the attendants to 
indigestion or to gastric disturbance of some kind, the possibility 
of an attack of erysipelas should at once suggest itself. Long 
before any of the characteristic local conditions about the wound 
are noticed, the presence of prodromal symptoms make themselves 
manifest. The tongue becomes heavily coated; there is a sense of 
oppression in the epigastrium, with malaise by day, and possibly 
with delirium at night. There may also be noticed occasionally 
some enlargement of the lymphatic glands, particularly those lead- 
ing from the part, indicating the route through which the absorp- 
tion of the poison is taking place. A day or two may pass before 
the local symptoms appear. In the mean time there is no percept- 
ible change in the condition of the wound — certainly not enough to 
account for the constitutional disturbance. Occasionally there may 
be an indisposition so slight that the patient is hardly conscious of 
it, and then the earliest manifestations noticed are in the wound 
itself. 

By far the most characteristic feature of this disease is the 
inflammation of the skin. The local inflammation is recognized 
by an increased feeling of tension in the wound, with increased 
heat and usually with an itching or a burning sensation. The 



ER YSIPELAS. 389 

ervthema often seen about a wound, and caused by hot poultices, 
bv tight stitches, or by other irritating features of the dressing, is 
easily distinguished from erysipelas, as the former is chiefly hyper- 
emia, and not accompanied by exudation, and is also limited 
entirely to the part irritated. Slight pressure will show that there 
has been no organic change in the tissues. As true erysipelas 
develops there is diffused redness and swelling more or less uniform 
in the centre, but at its edges showing a zigzag irregularity of out- 
line that is quite characteristic, one writer having likened it to the 
burned edges of a sheet of paper. The color is not of that rosy 
tinge which pure hyperaemia produces, but it has a somewhat more 
dusky hue. There is mingled with the red a yellowish tinge which 
becomes more evident on pressure, for then there is noticed a dis- 
tinct yellowish staining of the skin during the brief moment that 
the blood is absent from the capillaries. Pressure also shows that 
there is considerable hardness of the inflamed part; there is usually 
no perceptible pitting on pressure, except in anatomically loose tis- 
sues like the eyelids or the scrotum. There is, in fact, a picture 
of inflammation, of a very superficial character, of the cutis vera, 
with an exudation of considerable amount in that structure and in 
the underlying looser tissues. As the inflammation increases in 
severity there can be detected with a lens minute vesicles situated 
here and there or in large numbers. Many of these vesicles run 
together and form bullae of considerable size, which are filled first 
with a clear and slightly yellowish serum that subsequently 
becomes turbid or at times becomes even purulent. The smaller 
vesicles soon dry and form yellowish or brownish scabs, so that 
during the resolution of the inflammation there may be consider- 
able desquamation. 

As soon as the local inflammation is once developed it shows a 
tendency to spread in various directions. The outline continues to 
be well marked, and, as has been shown, it is strikingly irregular 
or zigzag, this peculiar appearance being due to the anatomical 
arrangement of the lymph-channels along which the cocci spread. 
The general direction of spreading is, when on the extremities, 
toward the trunk; when on the face, toward the scalp; but at times 
the route which the disease takes when starting from a wound 
may vary greatly. It may meander over a great extent of surface. 
The writer has seen it invade the entire surface of the body. Such 
forms of erysipelas have been called "wandering" erysipelas (am- 
bidans or migrans). The disease does not usually remain more than 
three or four days in any one place: it moves along, involving neigh- 



390 SURGICAL PATHOLOGY AND THERAPEUTICS. 

boring parts. Occasionally it may appear at a distant point, and it 
is then called "metastatic;" but this is a form seen chiefly in pyse- 
mic complications of the disease. The parts originally involved 
may become inflamed a second time after the inflammation has 
passed on to distant regions. This tendency to recur is quite cha- 
racteristic of erysipelas. Volkmann says: " It is like a fire over 
which one has no control; it burns on wherever it finds material, 
and it suddenly breaks out afresh in a spot where it was supposed 
to be extinguished." 

The duration of the disease is from one to two weeks. It is 
well to remember that there is always a tendency to recovery. It 
might even be called a "self-limited" disease. As the inflamma- 
tion fades away there is an abundant desquamation; the swelling 
subsides, and, inasmuch as in the ordinary typical cases of erysipe- 
las there is no suppuration, there is a complete return of the skin 
to its normal condition. But even after the disease has entirely 
disappeared there may still be a relapse even more severe than the 
original attack. The writer remembers the case of a lady who had 
erysipelas during the healing of a wound from amputation of the 
breast. The attack was severe, but she entirely recovered, and 
four months later, long after the wound had healed, a second 
attack occurred, from which she died. There may be repeated 
recurrences : PirogofTsaw from six to eight such cases, with a fatal 
termination in one case. Some patients have what is called 
" habitual erysipelas, " coming on at certain periods of the year or 
occurring always on certain parts of the body. In such a case 
there is usually considerable permanent thickening of the skin and 
subcutaneous tissue, giving rise to a condition resembling ele- 
phantiasis. 

During the progress of the attack there is generally a more or 
less marked change in the condition of the wound. If the healing 
process has only been going on for a few days in a case of union 
by first intention, the wound may reopen partially, and its edges 
will have a grayish, sloughing aspect. The lips of the wound will 
be swollen, and a thin, serous, purulent fluid will exude. At other 
times the healing process appears in no wise disturbed during the 
attack. In open granulating wounds the closing in of the edges 
may even proceed faster than before, owing to that so-called 
"curative" or stimulating action which erysipelas exerts. But 
usually the granulations lose their brilliant color and become dull 
and glazed, exuding a small amount of thin, sero-purulent fluid. 
Here and there hemorrhagic extravasations are noticed, and in cer- 



ERYSIPELAS. 



391 



tain spots the granulations lose their vitality and adhere to the 
wound as a rind or diphtheritic membrane. In deep wounds which 
are in the early stages of healing considerable sloughing of the 
underlying connective tissue may occur, and, if important vessels 
lie near, there may be some danger of secondary hemorrhage. 
Such a complication occurred once to the writer after ligature of 
the popliteal artery for aneurism. The hemorrhage, though quickly 
stopped by the nurse, was sufficient to prove fatal to a patient 
already exhausted by the disease. More rarely the wound may be 
attacked by true hospital gangrene, but such a complication is 
extremely rare at the present time. 

The constitutional disturbance which accompanies an attack of 
erysipelas is usually well marked. The gastric symptoms and the 
chill have already been alluded to. With the chill there is a rapid 
rise of temperature, which at times may reach as high as 105 F. 
With the first onset of the inflammation there is no marked remis- 
sion of the fever, a slight fall only being noted in the morning. 
The temperature varies in a most erratic manner, corresponding 
pretty closely with the local progress of the disease, but the tend- 
ency of the fever-curve is to assume the remittent type, and in 
the later stages this tendency is quite marked (Fig. 74). With 



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Fig. 74. — Traumatic Fever followed by Erysipelas in a case of Lithotomy. 



subsidence of the erysipelas there will be a defervescence with 
speedy return to the normal temperature, but occasionally the 
febrile disturbance continues, although the local inflammation 
has disappeared. There is usually in these cases a considerable 
rise of temperature in the evening, with a fall to the normal line 
in the morning. Such cases are apt to experience a recurrence of 



392 SURGICAL PATHOLOGY AND THERAPEUTICS. 

the local inflammation, and it is the writer's habit to have the 
patient thoroughly disinfected and removed to a different room, 
when all febrile disturbance speedily subsides. It has always 
seemed to the writer that in such cases there took place a sort of 
auto-inoculation by which the patient was reinfected by the micro- 
cocci that had been disseminated through the clothing and the 
apartment. 

After a severe attack of erysipelas the defervescence will often 
be followed by a subnormal temperature lasting at times for a week 
or two. There are, however, no other symptoms of collapse, and 
such a temperature is probably due to the feeble condition in which 
the patient is left. 

The other varieties of erysipelas that are usually recognized as 
such in America are the phlegmonous and the facial. 

In the phlegmonous variety the disease usually begins, as in the 
ordinary form, in the skin, and it extends subsequently to the 
deeper parts. The spreading downward of the process is usually 
indicated by an increased swelling of the part. The skin becomes 
more tense and harder. Vesicles and blisters form, which are some- 
times filled with a bloody fluid. The surrounding parts are swollen 
and cedematous. In the mean time the constitutional disturb- 
ance is greatly increased, and the fever is more continued in type 
and at times is of a typhoidal character. The formation of pus 
may be ushered in by chills, and at the point of suppuration the 
tense tissue will become soft and more or less fluctuating. A free 
incision gives vent to a thin and discolored pus in which may be 
found shreds of sloughing connective tissue. There does not 
appear to be a circumscribed collection of pus, but rather there 
is a purulent infiltration of the subcutaneous connective tissue. 
L,arge masses of sloughing tissue are eventually discharged, which 
masses have been likened to wads of wet chamois-leather or to wet 
blotting-paper. Usually several incisions are necessary to give free 
drainage to the pus and ichor and the masses of sloughing tissue. 
In the milder form the inflammation is usually confined to one 
region of the body, as the leg or the thigh or an arm and forearm. 
Occasionally, however, the disease assumes a more malignant type. 
The suppurative process spreads between the muscles, which may 
be dissected away from the adjacent parts for a considerable dis- 
tance. The periosteum may be attacked and the bones be laid bare 
to an extent that gives rise to necrosis. Ashurst, Volkmann, and Gos- 
selin describe a suppurative synovitis which appears to be caused 
by direct invasion of the joint by erysipelas cocci. The result 



ER YSIPELAS. 393 

of such a complication is of course a more or less complete disor- 
ganization of the joint, and when more than one joint is involved 
the termination of the case could hardly be otherwise than fatal. 
If the synovitis occurs late in the disease, when other symptoms 
are subsiding, the patient may escape with ankylosis. More fre- 
quently it is found in these severe forms of erysipelas that the 
intensity of the inflammation is expending itself upon the skin, 
and the disease then assumes the gangrenous type, although occa- 
sionally a most extensive burrowing of pus may take place beneath 
the skin without involving its vitality. Stille cites such an instance 
where the skin of the entire abdomen was dissected off the abdom- 
inal muscles. When, however, the gangrenous type develops, the 
skin becomes of a dusky red color which does not disappear on press- 
ure. Large bullae filled with bloody serum form, which, when dis- 
charged, have an offensive odor. At times the skin may become 
gradually pale and white or marbled. The sloughing process will 
extend more or less deeply, and fasciae, muscles, or arteries will be 
exposed and be involved. At times the gangrene will be limited 
to certain isolated patches of skin whose vitality has been impaired 
by the violence of the inflammatory process; at other times the 
gangrene will involve large areas and will develop at an early 
stage of the inflammation. The tendency to form pus is slight, 
and on incising the parts a foul, discolored serum will ooze from 
the wound. The constitutional symptoms will become graver at 
the same time. Such types are most frequently met with in old 
subjects enfeebled by disease or by intemperance, or in young chil- 
dren affected with tubercle. They are found also in the course of 
malignant epidemics such as occurred in 1843 ^ n America. 

Some of the malignant types of inflammation associated with 
felon and palmar abscess are distinctly erysipelatous in their nature, 
and are caused by wounds from infected instruments, or they follow 
injuries received during the handling of a cadaver. Medical stu- 
dents are occasionally subjected to this affection, and also those 
who may come in contact with meat or food in a state of decom- 
position, as butchers and cooks. The inflammation, starting from 
a slight prick or abrasion on the finger, spreads rapidly up the hand 
and arm. The lymphatics are usually at first involved, as indicated 
by red streaks extending up the inner side of the arm. The whole 
limb, however, may become the seat of an acute and rapidly-ex- 
tending inflammation. The tendency to suppuration is slight, but 
the amount of exudation is excessive, and the oedema may spread 
even over the shoulder and chest. Although such cases would not 



394 SURGICAL PATHOLOGY AND THERAPEUTICS. 

be classed by every surgeon in the category of erysipelas, yet Till- 
mans regards them as such, owing to the tendency of the disease 
to spread. The conditions found correspond with what one would 
expect to result from the action of a malignant streptococcus growth 
— namely, rapid spreading with slight tendency to suppuration. 
Such cases resemble closely the so-called "malignant oedema" 
of Pirogoff. As to the gangrene fondroyante of Maissonneuve, 
which is also looked upon by Tillmans as a malignant form of 
erysipelas, it may be said that there are types of erysipelas where 
there occurs extensive sloughing of the skin as well as of the parts 
beneath; but the condition of rapidly spreading gangrene of an 
entire limb with acute putrefaction, which follows injury to blood- 
vessels or nerves, can hardly be classed with erysipelas merely be- 
cause of its tendency to extend itself quickly over a large surface. 

The acute inflammations of the fingers and hand, although 
usually terminating speedily in suppuration, as in felon or in 
palmar abscess, may occasionally assume a distinctly erysipelatous 
type. They are accompanied with great pain and constitutional 
disturbance, the patient usually seeking relief as soon as possible, 
and they should be promptly dealt with. It is important to 
remember that a hand or even a life may be saved by active inter- 
ference. 

In the case of a laundress such an inflammation, involving the finger and 
a portion of the back of the hand, was immediately arrested by free incis- 
ions a few hours after the first symptom of trouble had been noticed. No 
pus escaped, but a turbid serum oozed from the wounds. 

Inflammation of the scrotum and penis of a severe type is 
described arising independently of any urethral complication. 
The liability of this region to great distention in acute inflam- 
mations would make it a favorite seat of the gangrenous type 
of erysipelas. In other regions, when the tendency to oedema is 
great, serious complications may result. In a case of erysipelas of 
the face and neck following a rhinoplastic operation the swelling 
of the neck was excessive, and pressure upon the glottis produced 
a dyspnoea that could be relieved only by tracheotomy. 

Facial erysipelas has sometimes been called ' ' idiopathic erysip- 
elas, ' ' the idea having generally prevailed that this form of the 
disease was non-traumatic in origin. Although the possibility of 
an infection through the mucous membrane has already been con- 
sidered, the opinion has of late years been gaining ground that the 
majority of cases arise from some slight solution of continuity in 
the skin itself. It may even happen that at the moment of the 



ERYSIPELAS. 395 

breaking out of the disease the little wound may have already 
healed, and the erysipelas takes its origin from the germ contained 
in the freshly-formed cicatrix. The attack is usually ushered in 
with a chill which is sometimes of great severity, but the presence 
of enlarged glands, which may appear before the blush upon the 
skin, is considered quite characteristic. The most frequent point 
of departure of the inflammation is the root of the nose. Accord- 
ing to Raynaud, the spot where erysipelas first appears is one of 
the lachrymal ducts, through which the disease emerges from the 
corresponding nasal fossa, which is endowed with lymphatic ves- 
sels emptying themselves into the submaxillary lymphatic glands. 
Under the circumstances one would expect to find the lymphatic 
glands enlarged and painful. 

Starting from the bridge of the nose, the inflammation spreads 
laterally across the cheeks toward the ear, rarely involving the tip 
of the nose. It is said to have a preference for the right cheek. 
The characteristic irregular outline marks its progress as it gradu- 
ally spreads over one or both cheeks and finally involves the entire 
face. The color is a scarlet-red, tense and shining, shading off 
into a darker hue at the ears. The eyelids are the seat of an 
cedematous swelling which completely closes them, and the expres- 
sion of the face is so changed as to render the latter unrecogniz- 
able. The nostrils are obstructed so that the patient is confined to 
mouth-breathing. The swelling of the ears is also sufficiently great 
to impair the hearing. The chin is rarely involved, this being 
accounted for by the fact that the lymph-stream carries the virus 
from the upper lip directly to the submaxillary region. The sur- 
face of the skin is roughened by the presence of minute vesicles 
which may run together and form bullae whose contents may at times 
be mixed with blood or with pus. The inflammation may involve 
a portion of the neck, but more commonly it invades the scalp, in 
which region the color is much less marked, and might be over- 
looked when the hair is abundant. There is, however, considerable 
swelling, pressure is painful, and the glands at the back of the neck 
are enlarged and sensitive to the touch. 

An aggravated form of the disease will be accompanied with a 
high temperature which is more or less characteristic. During the 
early stages of the inflammation the pyrexia will be of the con- 
tinued type with slight evening exacerbations, the temperature 
varying from 103 to 104° F. At the end of four or five days there 
will be a defervescence which is usually quite rapid. Before the 
temperature becomes normal, however, there will be one or more 



39 6 SURGICAL PATHOLOGY AND THERAPEUTICS. 

exacerbations which are caused by local outbreaks of erysipelas. 
During the height of the fever there is, in most cases of this 
variety, more or less delirium, which is explained in the majority 
of cases by an irritation of the cortical substance of the brain 
due to reflex nerve-action or disturbance of the vaso-motor sys- 
tem, or by the sepsis which causes the fever. The extension of the 
disease to the scalp is accompanied by an aggravation of the brain 
symptoms, but it is rare that any pathological changes are found in 
the brain or its meninges to account for them. Suppurative men- 
ingitis, when it exists, is usually caused by direct extension of the 
erysipelas into the orbit — a locality where abscess may occur — and 
thence by a continuation of the suppurative process to the mem- 
branes through the orbital fissure. The delirium, therefore, is not 
necessarily a dangerous symptom, and ordinarily it disappears with 
the subsidence of the fever, 

The tendency of the inflammation to involve the tissues of the 
orbit is a characteristic symptom of the graver form of facial 
erysipelas. The distention of the eyelids is so great as to cause, in 
rare cases, gangrene. Considerable disturbance of vision may be 
caused by conjunctivitis, by congestion of the sclerotic, by cloudi- 
ness of the cornea, and by oedema in the orbit, but the latter 
symptom will disappear with the subsidence of the inflammation. 
If there is deep-seated pain and protrusion of the eyeball, with dis- 
turbed or complete loss of vision, an extension of the erysipelas 
to the eye itself may be feared. Blindness, which is occasionally 
seen as the result of facial erysipelas, is caused by atrophic degen- 
eration of the optic papilla or by panophthalmitis with suppuration 
and destruction of the eye itself. 

Erysipelas neonatorum, which is a very fatal malady, is rarely 
observed outside of hospitals. The close connection between this 
disease and puerperal fever has already been alluded to. The 
period at which it is most frequently seen is at the time of separa- 
tion of the umbilical cord, and it is from the granulating surface 
of the stump that it takes its origin. At first there is but little 
fever, and the slight blush about the navel or the pubes is often 
regarded as an unimportant symptom. The skin, however, soon 
becomes a brighter red, and the subcutaneous cellular tissue is 
indurated and swollen. The next day the inflammation has spread 
to the genitals and the thighs, below and over the abdomen. The 
constitutional symptoms now become strongly marked: there is 
high fever with great prostration; the child cries, and there is 
great restlessness. The skin in the later stages may become gan- 



ERYSIPELAS. 397 

grenous, or phlegmonous inflammation may occur. Finally, the 
patient falls into a state of collapse, and succumbs to the disease 
on the sixth or the tenth day. Inflammation of the tissues and the 
navel is well marked. There may be found both periarteritis and 
periphlebitis. The tendency of the arteries to become involved is 
due to the great thickness of the periadventitial tissue, which is 
nearly double that seen in the veins. The inflammation extends 
to the point at which the hypogastric arteries are reflected upon the 
walls of the bladder. When phlebitis occurs, it will extend along 
the walls of the veins and into the liver. Pus may be found in the 
surrounding cellular tissue, and peritonitis may also be a complica- 
tion, and even the pleura may be affected. A peculiar sclerosis of 
the cellular tissue of the affected parts has been described, particu- 
larly of the lower extremities and the pubes. Patches of brown 
and discolored skin mark the seat of this lesion, but the question 
whether this affection is to be regarded as a complication of gen- 
uine erysipelas is considered by Tillmans as doubtful. 

Erysipelas is found not only in the skin, but occasionally also in 
the mucous membranes. Attention has already been called to the 
fact that nasal erysipelas is one of the most frequent points of 
departure of facial erysipelas. Raynaud states that the advent 
of the latter affection may be foretold by the swelling of the 
lachrymal duct caused by the passage of the inflammation 
through that canal. When the pharynx is involved there is 
seen in the beginning a marked enlargement of the submaxil- 
lary and cervical glands. There is a burning sensation in the 
throat, with dryness and a tendency to dyspnoea or difficulty in 
swallowing. The color of the throat is a dark red, diffused or in 
patches, and the swelling is considerable, involving more or less 
the tonsils. Later, vesicles form, which vesicles soon break and 
evacuate a serous or sero-purulent liquid, leaving behind little yel- 
lowish-white patches which are easily removed. The disease lasts 
five or six days. Occasionally the throat may become the seat of a 
gangrenous or diphtheritic inflammation, or there may form an 
abscess somewhat similar to the retropharyngeal abscess. In some 
cases there is an extension of the inflammation to the mouth, the 
tongue in this event becoming more or less swollen. In malignant 
epidemics, such as that described as occurring in 1842 in America, 
the enormous swelling of this organ gave rise to the name given to 
the epidemic itself — "black tongue." 

The inflammation may make its way from the pharynx through 
the Eustachian tube to the external auditory canal and thence to 



39§ SURGICAL PATHOLOGY AND THERAPEUTICS. 

the head and scalp. The mucous-membrane inflammation may 
also be secondary to the facial erysipelas, the disease finding its way 
in through the mouth, nose, lachrymal duct, or auditory canal. 

The disease does not stop at the pharynx, but may extend down as 
far as the glottis; it usually stops here, and only occasionally extends 
and gives rise to oedema of the glottis. Such a complication is of 
course nearly always fatal. Finally, the inflammation may be 
traced as far as the lungs, in which case all the symptoms of pneu- 
monia may develop. Trousseau described erysipelatous pneumonia, 
or pneumonia migrans, which differs from the common form in not 
involving an entire lobe, but, beginning insidiously and involving 
a circumscribed area, it moves from place to place, an apparent 
resolution taking place in the parts successively involved, until the 
entire lung becomes affected, and even double pneumonia may 
result. This form runs its course slowly, and there are frequent 
improvements with relapses. Raynaud does not accept the identity 
of this form with true erysipelas unless a distinct extension of the 
disease from the skin or the mucous membrane has taken place. 
Without a coexisting erysipelas it would not be justifiable to make 
such a diagnosis. 

That erysipelas may involve the female genitals has already 
been shown. The rectum is occasionally also the seat of the dis- 
ease by extension from the nates. The writer had an opportunity 
of observing this form in a case of cancer of the rectum, the dis- 
ease breaking out after a digital examination. Both nates were 
extensively involved. Complete relief of the symptoms of stric- 
ture followed, and an examination later showed that the cancerous 
mass had disappeared. Unfortunately, there was eventually a 
return of the carcinoma. 

The principal anatomical seat of the disease is in the skin. If 
this organ be examined, the cells of the epidermic layer will be 
found much swollen or raised up by fluid in the form of blisters. 
The cells of the rete are enlarged and swollen, and there is a serous 
infiltration of the lining membrane of the hair-follicles and the 
sweat-glands. In the upper layers of the true skin there is a rich 
capillary network of lymphatic vessels, and this region is the prin- 
cipal seat of the coccus growth. The cocci are seen crowding these 
capillaries and spreading also into the connective-tissue spaces. 
The bacteria are most numerous near the margins of the erysipe- 
latous blush. In the neighboring parts, which have not yet been 
attacked, cocci are more or less numerous in the lymphatics of the 
skin, and even in the subcutaneous tissue. Near the red border 



ER YSIPELAS. 399 

they have already reached their highest degree of development. 
The lymphatics are so crowded here with cocci that the leucocytes 
are not visible. The cocci may also be found between the bundles 
of connective-tissue fibres. Within the border-line there are 
greater hyperaemia and exudation of leucocytes, which are seen 
emigrating from the blood-vessels in large numbers. Proliferation 
of the cells of the connective tissue is also going on, but these 
cells do not appear to take any active part in the process. Nearer 
the centre of the diseased area the cocci are no longer to be seen, 
but the inflammatory exudation has reached its highest point. The 
vesicles on the surface are filled with a turbid serum, but the cocci 
are seen here only in small numbers. When the growth of the 
cocci is unusually active the surrounding tissue undergoes necrosis 
and minute abscesses may form. Undoubtedly many such abscesses 
develop, and they are subsequently absorbed without any external 
indication of their presence. In the more malignant types of ery- 
sipelas suppuration occurs on a larger scale, and it is probable that 
this process is due to the activity of the erysipelas cocci, which 
occasionally seem to possess true pyogenic qualities. After an 
active growth in various directions the organisms cease to continue 
their development, and the further progress of the disease is thus 
arrested. 

The micrococci are not found in the capillary blood-vessels of the 
part affected. That a certain number of them find their way into 
the circulation has been abundantly proved. The reason why 
metastatic foci of inflammation are not thus established is to be 
found in the fact that after leaving the original seat of their devel- 
opment the organisms are speedily destroyed. 

Masses of micrococci are occasionally found in distant organs 
and in the enlarged glands. Although bacteria are found in the 
blood only in small numbers, the peculiar changes seen in the 
blood-corpuscles have been attributed by Heuter and others to 
the presence of the micro-organisms. The precise reason for 
these changes is not yet clear. The red blood-disks assume a 
peculiar crenated appearance. They not only shrink, but readily 
dissolve and run together, looking, as Stille says, like streams of 
yellow fluid crossing the microscope. Fatal hemorrhages occurring 
during the progress of the disease have been ascribed to this condi- 
tion of the blood. The white corpuscles are usually increased in. 
number. Endocarditis may occur, involving the bicuspid and 
mitral valves, and also pericarditis. A slight systolic murmur is 
frequently heard, which usually disappears with the erysipelas. 



400 SURGICAL PATHOLOGY AND THERAPEUTICS. 

The condition of the heart-action may largely be due to the state 
of the blood and to some fatty degeneration of the muscular tissue. 
Fatty degeneration of the diaphragm is sometimes also noticed. 

The gastric disturbance so characteristic of this disease is not 
explained by any well-marked local changes. It is probably due 
to the general septic condition of the system. Ulcerations of the 
small intestines, such as are seen following extensive burns, are 
occasionally found. They are probably of catarrhal origin, and 
may be the cause of the bloody diarrhoea which is occasionally 
observed. 

The cerebral symptoms which occur in facial erysipelas would 
lead one to expect marked changes within the cranial cavity; but 
this is not the case. The brain and the membranes may be some- 
what hyperaemic and cedematous, and the large sinuses and the 
veins may be filled with dark serous blood and thrombi in a lim- 
ited number of cases. Suppurative meningitis, which is extremely 
rare, results from the invasion of a phlegmonous inflammation 
through the orbit. 

Among the other material changes may be noted enlargement 
of the spleen, parotitis, and cloudy swelling of the kidneys. Neur- 
itis may be found in rare cases in the nerves of the parts affected, 
which affection may give rise to muscular contractions. In grave 
cases, when pysemic infection has become a complication, there 
may of course be found the numerous pathological changes result- 
ing from sepsis. 

The curative influence of erysipelas when it occurs in the 
course of other chronic diseases has already been mentioned. 
Occasionally the Wound itself will seem to heal more rapidly, 
and the granulations to have a more ruddy and vigorous appear- 
ance than existed previous to the attack. Chronic inflammations 
of the skin, particularly those of a tuberculous or syphilitic cha- 
racter, have been known to yield to an attack of erysipelas that 
resisted all kinds of treatment. Volkmann, Grivet, and others 
report quite a number of cases of lupus permanently cured in 
this way. Chronic ulcers of the leg have been stimulated to 
heal, and also old sinuses connecting with joints or bones. The 
therapeutic use of the products of the organism will be discussed 
elsewhere. (See Appendix.) 

Raynaud reports, in Ricord's clinic, a case of phagedenic chancre which 
for two years resisted all kinds of treatment. Finally, Ricord suggested 
that an attempt be made to bring on erysipelas. All kinds of irritating 
dressings were tried in vain, as well as charpie saturated with pus. Two 



ERYSIPELAS. 40 1 

months later, erysipelas appeared spontaneously, and the chancre was 
healed in a few days. 

Old neuralgias often improve after an attack of erysipelas, and 
likewise in the insane a temporary improvement has been observed. 
The disappearance of tumors has been frequently noticed. The 
writer has already called attention to a case of cancer of the rec- 
tum in which the growth melted away before an attack of erysip- 
elas. Tillmans and Coley have collected a number of cases of 
sarcoma cured in this way. (See Sarcoma.) 

A woman forty-three years old, having a sarcoma the size of an apple on 
the left cheek and two other sarcomatous nodules on the face, was operated 
upon by W. Busch for the removal of a lobe of the larger tumor. Two days 
later erysipelas appeared and considerably diminished the size of the tumors; 
after a relapse they disappeared entirely. 

A man twenty-eight years of age, having a large incurable lympho-sar- 
coma of the left side of the neck extending from clavicle to parotid, after 
entering the hospital had facial e^sipelas which involved the neck. During 
the illness, which lasted eight days, the growth diminished one-half in size. 
Two days later the patient died, and at the autopsy an extensive fatty degen- 
eration of the cells of the tumor was observed. 

The observation made in the latter case probably explains the 
process by which absorption takes place. The feebly resisting 
power of the diseased cells renders them less able to resist the 
action of the micro-organism. It must not, however, be supposed 
that erysipelas always has this effect upon morbid growths on the 
surface of the body. The writer has more than once seen epi- 
thelial ulcers of the face which had passed through an attack 
of the disease with their vitality unimpaired. 

The diag7iosis of erysipelas is usually not difficult when the 
inflammation of the skin is fully developed, lu the early stages, 
however, before the local symptoms appear, there is no sure guide. 
Gastric symptoms with febrile disturbance which cannot be ac- 
counted for after careful examination of the patient strongly sug- 
gest the near approach of erysipelas. Enlargement of the glands 
adjacent to the part affected is usually alluded to as an important 
sign, but it would not, in the writer's opinion, be wise to rely 
upon a mere enlargement unless the swelling be manifestly acute 
and be accompanied with indications of an adjacent skin-inflam- 
mation. 

The erysipelatous blush is sufficiently characteristic. The 
doughy swelling of the skin, the yellow infiltration, and the 
peculiar zigzag outline slightly raised above the level of the 
adjacent healthy skin are all sufficiently constant to avoid con- 

2G 



402 SURGICAL PATHOLOGY AND THERAPEUTICS. 

fusion with erythema, with inflammation due to abscess in the 
wound, or with irritation from tight stitches. In abscess there 
should be a rise of temperature, but in the other conditions the 
constitutional disturbance would probably be so slight as to show 
dearly their nature. There may be some difficulty in recogniz- 
ing erysipelas in certain regions, as in the scalp. The presence of 
inflammation on the face or the ears, together with enlargement of 
the occipital glands, will then help to establish the diagnosis. 

The difference between phlegmonous cellulitis and phlegmonous 
erysipelas is one w T hich in some countries is not recognized at all, 
and in general it is regarded difficult to distinguish between them. 
The cellulitis usually starts from a severe wound, owing to the 
failure of antisepsis in the early stages of the healing process. 
The most frequent example is that accompanying compound frac- 
ture. The inflammation in this case is essentially deep-seated, and 
the skin is not the seat of a distinct and independent inflammation, 
but it is involved only to such an extent as could be accounted for 
by the inflammation of the deeper-seated cellular tissues. The 
appearance of the suppurating tissues shows less tendency to gan- 
grene in cellulitis than in erysipelas. 

The prognosis of erysipelas is, on the whole, favorable. After 
a few days of inflammation there is a marked tendency to resolu- 
tion. The experience of different surgeons and physicians, how- 
ever, varies greatly. Stille never met with a fatal case of facial 
erysipelas where supporting or palliative treatment had been tried. 
He had, however, seen it fatal when evacuant, sedative, or altera- 
tive measures had been employed. Trousseau and Chomel, both 
of whom had a large experience in medical erysipelas, had hardly 
ever seen a fatal case of the disease. Gosselin, however, had a 
mortality of 20 per cent, in facial erysipelas. In surgical erysipe- 
las it was as high as 43 per cent. This is certainly an unfavorable 
showing — far more so than the experience of the majority of sur- 
geons of to-day would give. The sanitary surroundings of the 
hospital patient were probably far inferior to what they are at 
present, and it is possible that many of these cases may have 
occurred during the period of an epidemic, which always exerts 
an unfavorable influence upon the prognosis of the disease. 

The nature of the wound is supposed to be a factor in the ques- 
tion of mortality. Large or fresh wounds are considered as more 
likely to be followed by graver forms of the disease than small or 
granulating wounds. If the disease attacks the mucous membrane, 
as in the throat, it will probably be severe; if the vagina is the 



ERYSIPELAS. 403 

point of origin, as in puerperal cases, there may be reason to fear 
pyaemia or septicaemia. The deeper-seated types of the disease, 
such as the phlegmonous or the gangrenous, have undoubtedly a 
higher mortality than the cutaneous forms. 

In individuals enfeebled by long-standing suppuration, and in 
alcoholic subjects, the disease will prove a formidable complica- 
tion. The same may be said of a number of organic diseases, 
such as diabetes and Bright' s disease. For similar reasons youth 
and old age are periods of life when the patient is less resistant to 
its influences than when in the prime of life. 

Velpeau said that the disease was not dangerous in itself, but 
only through its complications, and in this opinion the writer's 
experience would lead him to agree. Secondary hemorrhage and 
oedema glottidis have led to a fatal termination in two cases which 
might otherwise have recovered. Even a mild form of the disease, 
without complications of any kind, may carry off an aged person. 
As a rule, however, it may be said that erysipelas is in the large 
majority of cases a mild disease, and one which has a strong tend- 
ency to get well of itself, quite independently of treatment. The 
writer's experience of fatal cases has been exceedingly small, and 
since the antiseptic system has been so highly perfected in all its 
details, the cases that do occur seem to run a milder course. At 
the present time the hospital surgeon has only to dread those cases 
which are imported into the hospitals, and which occur usually in 
neglected and enfeebled subjects. The cases of facial erysipelas 
which the writer has met with in private practice have nearly 
always been severe. The fever, the facial deformity, and the cer- 
ebral symptoms make a formidable group. The writer does not 
remember, however, to have seen but one fatal case. 

The treatment of erysipelas may be divided into local and con- 
stitutional. Of the latter form there has always existed two prin- 
cipal varieties, which, in general, may be divided into supporting 
and depletive. Depletion is an inheritance from ancient times, 
when venesection, emetics, and purgatives were the fashion. The 
object of bloodletting, and the reason that it at one time became a 
more or less popular treatment in the disease, was the effect pro- 
duced upon the circulation of the brain and the consequent relief 
given to cerebral symptoms. It may have acted also as a ready 
method of eliminating the virus from the system, although the 
number of cocci found in the circulation is not sufficiently large, so 
far as our knowledge at present goes, to enable one to say that they 
would be removed in any considerable number in this way. It can 



404 SURGICAL PATHOLOGY AND THERAPEUTICS. 

be conceived that occasionally the conditions existing in a particu- 
lar case would justify venesection. In a case of facial erysipelas in 
a plethoric individual with violent delirium a resort to this mode 
of treatment might be justifiable, but the surgeon should hesitate 
to advise it in other than exceptional cases. Apart from the pos- 
sible infection at the point of puncture, and the possibility of the 
formation of a septic thrombus, the danger of lowering the vitality 
in a disease which not infrequently has a typhoidal tendency is not 
lightly to be regarded. 

Emetics are now so rarely given for any disease that it seems 
hardly necessary to say a word about them. They may, however, 
be classed with cathartics as a method of eliminating the virus, for 
it is probable that the only benefit that could be derived from a 
cathartic would be this. A laxative might be given at the outset 
if there is reason to believe the bowels are overloaded. Caution 
should be observed in this disease to avoid any form of treatment 
that would act in a depressing way upon the system, and, as a rule, 
it would be prudent, therefore, not to adopt any of the measures 
which have just been alluded to. 

A great variety of internal remedies have been suggested that 
were supposed to possess special virtues in this affection, the most 
prominent of these being iron. By English writers iron has at 
times been regarded as almost specific in its action. It was first 
recommended by Hamilton Bell, who gave 25 drops of the tincture 
of the chloride of iron every two hours day and night. The theory 
of the action of iron is probably based upon the influence which the 
cocci are supposed to have upon the red corpuscles. The readiness 
with which they assume a crenated or shrunken appearance has 
been ascribed to the loss of haemoglobin removed from them. Iron 
is also supposed by Stille to have a constricting action upon the 
blood-vessels. 

A large number of English writers endorsed the treatment of 
Bell, but in all the latest publications the writer finds the statement 
of Pick quoted, that, although he has used it in drachm doses every 
two hours, he has failed to obtain any benefit from it. In the 
writer's experience iron has not seemed to have exerted any special 
action upon the disease, although he has not given it in so frequent 
doses as is advised by the English school. Iron has received endorse- 
ment from other nations as well as England, both French and Ger- 
man writers having used it with satisfactory results. Stille also 
gives the drug his endorsement, although he believes the measure 
of its utility is not always the same. It seems to him best adapted 



ER YSIPELAS. 405 

to the less sthenic forms of the disease or to those cases where 
marked debility is present. Cerebral symptoms do not appear to 
contraindicate its use. 

PirogofF strongly recommends camphor: he finds immediate 
results on the use of frequent doses during the first twenty-four 
hours. It is said not only to diminish the fever, bringing on a 
profuse perspiration, but also to lessen the delirium. It must not 
be used continuously for any length of time, as ''camphor delir- 
ium 1 ■ may be produced. Digitalis and aconite are among the 
remedies that have had their day in the treatment of this disease. 
The drug used perhaps more frequently than any other is quinine. 
It has been supposed to exert an action on the cocci through its 
power to arrest the migration of the white corpuscles. But as this 
does not afford an adequate explanation, it has been supposed also 
to act in virtue of its antipyretic power. According to Stille, it 
seems to act as well in small and moderate doses as in large anti- 
pyretic doses. The writer is in the habit of omitting it when the 
cerebral symptoms are urgent, but he gives it usually in 5- to 
10-grain doses, in combination with iron, three or four times a 
dav. Its tonic action gives it a decided advantage over manv 
other drugs. 

"The use of alcoholic stimulants in ordinary cases of the dis- 
ease is not only unnecessary, but injurious," according to Stille. 
Tillmans, however, recommends the administration of alcohol as a 
most valuable remedy both as a stimulant and as an antipyretic, 
and he is in the habit of prescribing a mixture of sherry with 
champagne. Under the action of the alcohol, he thinks, with 
suitable nourishment, one sees the disappearance of cerebral symp- 
toms. Pick advises the use of stimulants in almost all cases, even 
from the commencement, and occasionally in large quantities. 

In the milder forms of erysipelas it is the writer's habit to relv 
chiefly upon food to preserve the patient's strength. In old or 
feeble subjects, in the typhoidal types of the disease, or in cases 
when the amount of nourishment is insufficient from any cause, 
alcohol is clearly indicated. It is important to remember that 
delirium does not necessarily contraindicate its use, and that, on 
the contrary, in many cases nervous disturbance may disappear as 
the action of alcohol upon the system begins to be felt. Should it 
be necessary to use other measures to keep the patient quiet, the 
bromides, chloral, and even opium, can be employed without dan- 
ger. The antipyretics have but little influence upon the course of 
the fever, as their action is but temporary, and they do not belong 



406 SURGICAL PATHOLOGY AND THERAPEUTICS. 

to the class of drugs which would be used appropriately in a sup- 
porting treatment. 

There is hardly any disease upon which such a vast array of 
salves and lotions have been expended as erysipelas. In the 
writer's student days, when erysipelas was the constant companion 
of the hospital patient, local applications were confined chiefly to 
the margin of the blush, the adjacent healthy skin being painted 
with a narrow stripe of nitrate of silver to prevent the further prog- 
ress of the inflammation. Fresh applications were made as the 
disease crossed the line thus drawn. Tincture of iodine was used 
in the same way, but it was also painted extensively over the 
inflamed surface, and it probably exercised an antiseptic action 
upon the micro-organisms in the skin. As a local application car- 
bolic acid is probably used at the present time more than any other 
drug. White thinks that he can obtain absolute control over the 
disease by an application of an evaporating lotion of \ drachm 
of crystallized carbolic acid to 4 ounces each of alcohol and water, 
the part being kept wet with this solution either constantly or on 
alternate hours during the day and evening. The disease should 
yield to this treatment within forty-eight hours. 

Heuter first recommended subcutaneous injections of carbolic 
acid in 2 per cent, or 3 per cent, solutions. The injection should 
be made near the border of the diseased part, and about two 
Pravaz syringefuls should be used at one time, the dose being 
repeated at intervals of one or two days. The material injected 
should be spread over as great a surface as possible by passing the 
point of the needle in various directions. This precaution is taken 
to avoid abscesses, which have been observed to form at the point 
of puncture. The number of doses is subsequently increased to 
four or five daily. The erysipelas usually spreads over the first 
points of injection, but it is arrested on the third or the fourth day. 

A simple and comfortable way to apply carbolic acid is with 
liquid vaseline as a vehicle. It can be painted on the diseased 
surface with a soft brush. If a considerable area is to be cov- 
ered, it would not be advisable to use a stronger solution than 1 
per cent. In the early stages, when a small patch of the disease 
exists, a 5 per cent, solution may be used to advantage. The part 
can be protected by covering the vaseline with a film of gutta- 
percha tissue or with oiled paper. Whatever way the drug be 
used, it is hardly necessary to say that in the earliest period of 
the disease the treatment is likely to be far more effective. This 
rule applies with especial force to subcutaneous injections. 



ER YSIPELAS. 407 

Carbolic acid in a mild form can be brought to bear upon the 
disease through the agency of the class of preparations to which 
belong creolin and phenyl. These preparations can be applied in 
a strength of 2 per cent, on hot poultices of cotton or other mate- 
rial. Such a method is well adapted to erysipelas of an extremity. 
The treatment can be made more effective by holding the hand or 
the foot for an hour thrice daily in a hot bath of the same solution. 
The advantage of these preparations is that they are not liable to 
cause carbolic-acid poisoning — a complication which should always 
be kept steadfastly in mind when applying this drug over large 
surfaces. Concentrated solutions of salicylic acid have been 
injected subcutaneously around the borders of the diseased tis- 
sues, and a solution of sulphocarbolate of soda has also been used 
in the same way. 

The discomfort caused by the swelling of the skin is greatly 
relieved by any soothing material which can be so applied as to 
exclude the air. Dusting on starch or burnt flour accomplishes 
this exclusion, but it is soon brushed off or is caked up into 
dry masses. The frequent application of oil or of vaseline to 
the face with a soft camel' s-hair brush relieves the sensation of 
burning and stiffness, and it is generally a very soothing remedy. 
White paint has been used in the same way. A drug which 
involves the adjustment of a dressing to the face is much less 
agreeable to the patient. Frequent changes of temperature should 
be avoided, and exposure to cold, it is needless to say, is liable to 
aggravate the symptoms of inflammation. 

The treatment of the wound, if there is one, should vary greatly 
according to the changes which have taken place in it. Occasion- 
ally no change of dressing will be necessary, but if there is much 
sloughing of connective tissue, free drainage must be secured and 
appropriate antiseptic remedies must be supplied. In phlegmonous 
erysipelas, it is important to recognize pus as early as possible, and 
to give it free drainage by multiple incisions if necessary. It is in 
these cases that prompt surgical interference may be productive of 
the best results. The tendency of the poison to spread along the 
loose connective-tissue spaces must be checked promptly, no mat- 
ter how long or how numerous the incisions. Very hot and large 
antiseptic poultices are now indicated, and they should be changed 
several times a day, combined, if necessary, with antiseptic baths, 
as every opportunity should be offered for a discharge of the slough- 
ing tissues. The graver forms of gangrenous erysipelas or malig- 
nant oedema must be dealt with promptly and heroically by long 



408 SURGICAL PATHOLOGY AND THERAPEUTICS. 

and deep incisions. Many a life has been saved by the prompt 
interference of the surgeon. Small incisions, under these cir- 
cumstances, are worse than useless. 

In phlegmonous erysipelas of the face pus forms in the orbital 
fat, necessitating an incision between the eye and the orbital 
margin. In scrotal erysipelas of a phlegmonous or a gangrenous 
character a free incision should be made through the raphe, com- 
pletely dividing all the tissues involved. This incision usually 
results in a prompt arrest of the inflammatory process, and the 
wound heals rapidly. 

In the treatment of erysipelas of the mouth, the nose, and the 
fauces the practitioner must be guided by the general principles 
that govern the antiseptic treatment of septic inflammations of that 
region. Applied in the form of spray, antiseptic drugs may not 
only control the activity of the coccus, but they may help also to 
ward off the complications that may arise from cedematous swelling. 

In the vagina iodoform powder may be used freely, and antisep- 
tic douches should frequently be given. 

As soon as the diagnosis of the disease has been made the 
patient should be removed from a ward containing other cases, 
and complete isolation of the case should be preserved. This 
point should be strongly insisted upon, as, until very recently, 
erysipelas has not been regarded as a contagious disease. The 
thorough demonstration of its bacterial origin ought at the pres- 
ent time to leave no doubt in any reasonable mind upon this 
point. It is important also to realize that with the desquamation, 
which sets in early, the apartment is soon filled with the germs of 
the disease, and that thorough ventilation and frequent change of 
clothing and sheets are therefore matters to receive especial atten- 
tion. The tendency to relapse, so characteristic a feature of the 
disease, may find its explanation in the infection of the wound 
from the patient's own surroundings. The writer has not infre- 
quently seen a chronic and relapsing type of the disease arrested, 
or a tendency to undue prolongation of the pyrexia cut short, by 
removing the patient to another room. During the period of con- 
valescence the treatment should be tonic and supporting, and care 
should be taken to avoid exposure to cold, to draughts, or to 
fatigue. So long as desquamation lasts isolation should be con- 
tinued, and in private practice the patient should not be allowed 
to mingle freely with other members of the household, especially 
during periods of epidemics, until it is tolerably certain that the 
diseased organisms have been eliminated from the system. 



XVII. HOSPITAL GANGRENE. 

The task devolving upon the writer in this chapter is one 
of unusual difficulty, for the disease to be considered is one with 
which few teachers of to-day have had experience and which 
students never see. The impress of the antiseptic treatment of 
wounds having been sufficiently strong to stamp out, at least for 
the present time, one of the most baneful of the traumatic infec- 
tious diseases, hospital gangrene has become a historic disease. 

It is not improbable, however, that many students of to-day may 
be brought in contact with it, for, although the discipline of hos- 
pital surgery has banished the disease from the wards, it is pos- 
sible that cases may be brought into hospitals for treatment in 
the future, as they have in time past, or, what is more probable, 
that the disease may be met with in private practice. Paradoxical 
as it may seem, it is nevertheless true that hospital gangrene dur- 
ing the past decade has been seen only in private practice. As 
complete a disappearance of the disease has, however, been re- 
ported in former times, and it is highly probable that the occur- 
rence of war, of great epidemics, or of any disaster which may 
profoundly affect the present well-regulated system of hospital 
service or of surgical aid to the sick poor in large centres of 
population, will bring back this unwelcome guest. 

Hospital gangrene is a contagious traumatic disease character- 
ized by a diphtheritic wound-inflammation produced by a poison 
the precise nature of which is not yet fully understood, and it is 
usually accompanied by more or less profound septic constitutional 
disturbance. It has been known from the earliest times under 
various suggestive names, such as "wound-typhus," "wound- 
cholera," "pourriture d'hopital," "sloughing phagaedena," 
"nosocomial gangrene," etc. One of the earliest descriptions 
of the disease is by Pouteau in 1783. He describes it as ime 
maladie qui jiisqtt* a present rt a occupe la plume de personne. 
The most classic clinical descriptions of the disease were given 
by Dussaussoy in the latter part of the last century, and by Del- 
pech in 181 5, based, as they must have been, on an experience 
which could have been obtained only under the peculiar condi- 

409 



410 SURGICAL PATHOLOGY AND THERAPEUTICS. 

tions of that historical period. Indeed, "history" and gan- 
grene may be said to be coeval, and it is to the medical reports 
following great wars during the present century that surgeons 
are indebted for the most valuable data bearing upon the etiology 
and the treatment of the disease. Crowding of hospitals alone 
does not appear to be a sufficient cause, but when overcrowding 
follows the infliction of great privation and fatigue, the conditions 
most favorable for an outbreak of the disease seem to be obtained. 
A brief reference to some of the campaigns of late years will illus- 
trate these conditions. With Napoleon in Egypt the disease was 
reported as very fatal. According to Macleod, in the English army 
in the Crimean War the development of hospital gangrene resulted 
from the lowered general health rather than from specific causes. 
"It was in many cases a veritable child of the typhus." The 
French suffered much more severely than did the English. u The 
system they pursued of removing their wounded and operated cases 
from the camp to Constantinople at a very early date, the pernicious 
character of the transit, the crowding of their ships and hospitals, 
all tended to produce the disease and render it fatal when pro- 
duced." Many of their cases commenced in camp. On one of 
their transports sixty bodies were thrown overboard during the 
short passage of thirty-eight hours to the Bosphorus. The disease 
raged in the hospitals on the Bosphorus, and followed the returning 
wounded soldiers even to the hospitals in the south of France. 
" Both in the French and in the Russian hospitals gangrene was 
often combined with typhus, and in such cases the mortality was fear- 
ful." Men who had been wounded after unusual exertion seemed 
more susceptible to the disease. Macleod states that after the assault 
on the Redan not a few cases of amputation of the thigh were lost 
from gangrene of a most rapid and fatal form. In the camp at 
Scutari the wounds generally assumed an unhealthy aspect when 
the dreaded sirocco prevailed. 

During the Civil War the total number of cases reported by 
the Surgeon-General was twenty-six hundred and forty-two. 
The conditions under which some of the epidemics occurred 
are very suggestive. Keen reports one of the earliest which 
took place in 1862 in Frederick, Maryland, after the battle 
of Antietam. He says: "The old general hospital, which had 
contained six hundred beds, was so crowded with patients that 
one thousand were of necessity placed in the wards, and one 
thousand eight hundred men were fed at tables and slept some- 
where." About the middle of October, after some days of cold, 



HOSPITAL GANGRENE. 411 

rainy weather, the first cases were noticed. In December, when 
Keen left the hospital, fifty cases in all had occurred, with but 
two deaths. 

In 1863 an outbreak of hospital gangrene occurred in Annapolis, 
Maryland, among men who had recently been brought from Rich- 
mond, Virginia, all of w T hom had been closely confined in the 
prisons and prison hospitals of that city. "In the prisons they 
were much crowded, and the majority were unprovided with beds 
or cots, sleeping on straw which was foul and infected with ver- 
min." In the epidemic at Nashville, Tennessee, in the same 
year, the disease appears to have been of an indigenous origin. 
The cellar under the hospital had passing under and opening into 
it by several apertures the common sewer of that part of the city. 
The soil-pipes of the several wards emptied into the sewer without 
traps. The cellar opened upon an alley from which the infected 
ward derived its ventilation. The emanations from the cellar were 
most offensive at all times. Surgeon Goldsmith in his report states: 
k( I think that the records of surgery do not afford a more unique or 
striking example of one of the methods of the production of hos- 
pital gangrene." 

A still more striking example of the conditions favoring the 
development of hospital gangrene is to be found in the experi- 
ences of the Union soldiers in the Confederate prison at Ander- 
sonville, Georgia. The site of this prison, which was simply a 
stockade, and which afforded no protection of any kind, was 
selected by General Winder and was enclosed in November, 1863. 
The ground covered was about fifteen acres, but the space taken 
up by the various walls and the dead-line reduced the space to 
about twelve acres. The ground, which sloped toward the centre 
on either side, was divided into equal halves by a small, muddy 
brook. A part of the valley thus formed was a swamp. The 
refuse from the cook-house and the sewage from the guards' camps 
w T ere emptied into the brook, and thus rendered it unfit for drinking 
purposes, so that the prisoners relied chiefly upon wells which they 
made for the purpose. Every tree had been cut down and no shel- 
ter was afforded. No provision was made at first toward carrying 
off the refuse and sewage of the prison, and no sanitary regulations 
were put in force. " The only living things that seemed to thrive 
in this place were the flies, and they swarmed. Everything was 
covered with them, and they were responsible for the maggots that 
kept the swamp a moving mass of corruption " (Mann). Accord- 
ing to Jones, a morass of human excrement lined the banks of the 



412 SURGICAL PATHOLOGY AND THERAPEUTICS. 

stream. The greatest number of men accumulated at any one 
time is said to have been thirty-five thousand, and, although the 
mortality was enormous, this number was maintained by the fre- 
quent arrivals of fresh squads of prisoners. In the summer of 
1864, Lieut. -Col. D. T. Chandler of the Confederate service, who 
officially inspected the prison, begged the Richmond government 
to send no more prisoners. His report states : 

There is no medical attendance provided within the stockade ; small 
quantities of medicine are placed in the hands of certain prisoners of each 
squad or division, and the sick are directed to be brought out by sergeants 
of squads daily at "sick call " to the medical officers, who attend at the gate. 
The crowd at these times is so great that only the strongest can get access to 
the doctors, the weaker ones being unable to force their way through the 
press ; and the hospital accommodations are so limited that, though the beds 
(so called) have all or nearly all two occupants each, large numbers who 
would otherwise be received are necessarily sent back to the stockade. 
Many — yesterday twenty — are carted out daily who have died from unknown 

causes and whom the medical officers have never seen The sanitary 

condition of the prison is as wretched as can be, the principal cause of mor- 
tality being scurvy and chronic diarrhoea. Nothing seems to have been done, 
and but little if any effort made, to arrest it by procuring proper food — .... 
a place the horrors of which it is difficult to describe and which is a disgrace 
to civilization. 

The report of Crews Pelot, Asst. Surg. C. S. A. , states, in regard 
to the hospital accommodations : 

" A majority of the bunks are still unsupplied with bedding, while a por- 
tion of the division tents are entirely destitute of either bunks, bedding, or 
straw, the patients being compelled to lie upon the bare ground." After 
describing the insufficient supply of food and medicine, he adds: "Our 
wards — some of them — were filled with gangrene." 

During the month of August (1864), about the time when these 
reports were written, there were 31,678 prisoners in the stockade, 
and the number of deaths in that month amounted to 2993. 

About this time Dr. Joseph Jones was sent to inspect the condi- 
tion of the men at this prison. From his extensive and painstaking 
report are quoted the following details : 

" In the depraved and depressed condition of the system of these prison- 
ers, in the foul atmosphere of the stockade and hospital reeking with nox- 
ious exhalations, small injuries — as the injury inflicted by a splinter running 
into a hand or foot, the blistering of the arms or hands in the sun, or even the 
abrasion of the skin in scratching the bites of insects— are sometimes followed 
by extensive and alarming gangrenous ulceration." 

Dr. A. Thornbury reports to Dr. Jones that in Ward No. 5 at the Ander- 
sonville Hospital 325 cases of gangrene were treated during the months of 
July, August, and September (1864), and that out of that number 208 died. 



HOSPITAL GANGRENE. 413 

Gangrene first made its appearance in April of that year, and in many 
cases it was difficult to decide at first whether the ulcers were scorbutic or 
gangrenous. Small-pox also broke out at this time, and several thousand 
were vaccinated. As was to be expected, in every case affected with scurvy 
gangrene supervened in the vaccination-wound, and many of these cases died. 

The origin of the gangrene appeared to depend in a great measure upon 
the state of the general system. 

" In such a filthy and crowded hospital as that of the Confederate States 
Military Prison of Camp Sumter, Andersonville, it was impossible to isolate 
the wounded from the sources of actual contact of gangrenous matter. The 
flies swarming over the wounds and over filth of every description ; the filthy, 
imperfectly washed, and scanty rags ; the limited number of sponges and 
wash-bowls (the same wash-bowl and sponge serving for a score or more of 
patients), — were one and all sources of such constant circulation of the gan- 
grenous matter that the disease might rapidly be propagated from a single 

gangrenous wound In many cases gangrene attacked the intestinal 

canal of patients laboring under ulcerations of the bowels Amputation 

did not arrest hospital gangrene : the disease almost invariably returned. 
Almost every amputation was followed finally by death, either from the 
effect of gangrene or from the prevailing diarrhoea and dysentery." The 
exhalations from the gangrenous wounds of the Federal prisoners in the hos- 
pital and stockade appeared to extend their effects to a considerable distance 
outside of these localities. Thus the Confederate soldiers guarding the pris- 
oners, who did not enter the stockade or hospital, were in several instances 
attacked with hospital gangrene supervening upon slight abrasions or 
injuries. " In the gangrenous stumps examined after death the disorganiza- 
tion of the vessels and muscular tissue was widespread. Stumps from which 
gangrene had apparently disappeared, and which were thought to be doing 
well, were discovered after death to be thoroughly rotten within, notwith- 
standing that there was but little discoloration of the skin and comparatively 
little swelling. In the decayed state of the blood and in the depressed state 
of the forces gangrene appeared to affect the tissues with great rapidity and 
with but slight external marks of inflammatory action." 

The extent of mortality of this epidemic of hospital gangrene will 
probably never be known accurately; but, as the testimony of Col. 
Chandler shows that many cases of severe illness never came under 
the eye of the surgeon at all, and as Dr. Jones concludes that scurvy 
directly or indirectly caused nine-tenths of the deaths among the 
prisoners, and inasmuch as it is known that for one month alone 
the death-roll amounted nearly to three thousand, and that it was 
often difficult to distinguish in the beginning between scorbutic 
and gangrenous ulcers, and that when the epidemic was at its 
height nearly every abrasion become gangrenous, — some faint 
idea may be gained of the enormous number of cases of gan- 
grene that occurred. It is hardly necessary for the writer to say 
more about the role which bad food, unhealthy surroundings, and 
depressing influences play in the etiology of this disease. 



414 SURGICAL PATHOLOGY AND THERAPEUTICS. 

The Franco-German War, with all its greatly perfected medical 
equipments in both armies, was not exempt from this plague. It 
will serve no useful purpose to go into any of the particulars of 
this campaign: a single example will suffice: In the hospital at 
Brest three separate epidemics of gangrene occurred, each one fol- 
lowing the arrival of a convoy of wounded from the front. 

It was not alone in time of war that this disease flourished, 
and, although Joseph Jones makes the statement that it was un- 
known in the South previous to the Civil War, the writer cannot 
help feeling that the disease nevertheless existed, but was unrec- 
ognized. The following statement, taken from Jones's report, at 
least suggests such a possibility. Writing from the general hospital 
at' Staunton, Virginia (in 1863), Dr. Merillat says: "Fortunately, 
I have never had an opportunity of observing in this hospital the 
disease described in the books as hospital gangrene." He then 
proceeds to give an account of certain conditions of the wounds in 
his wards, which account is evidently a description of the ulcerat- 
ing form of gangrene. Certain it is that the disease was familiar 
to hospital surgeons in Boston and in Philadelphia, as the writer 
can testify from personal knowledge. A most malignant epidemic 
at the Massachusetts General Hospital is one of the earliest recol- 
lections of his professional career. This epidemic occurred at a 
period when the river flats adjoining the hospital grounds were 
filled in. One of the peculiarities of this epidemic was the fre- 
quent complication of erysipelas. 

The following case is taken from the records of October 1, 1864: Amputa- 
tion of leg at junction of middle and upper thirds for osteosarcoma ; on 
October 6, sloughing aspect of wound with exposure of both bones ; on the 
7th, chill ; on the 14th, complete separation of flaps by sloughing. The 
muscles are separated for some distance from the integuments. Some hem- 
orrhage from the main artery. Death occurred October 15. Many cases of 
amputation presented about this time very typical examples of the pulpy 
form. The wounds of stumps were enormousty swollen and everted. Second- 
ary hemorrhage was of frequent occurrence, and in several cases ligature of 
the femoral artery in Scarpa's triangle for hemorrhage was followed by gan- 
grene of the ligature-wound, and death. 

But few cases have been seen in the hospital since the introduc- 
tion of the antiseptic methods. A case of the ulcerating type the 
writer saw, however, in the summer of 1889, ^ n the wards, but 
failed to obtain from the surgeon in charge of the case a specimen 
for bacterial study. Unfortunately, at the time of the disappear- 
ance of hospital gangrene bacteriology had not reached that point 
of perfection which it since has, so that no satisfactory scientific 



HOSPITAL GANGRENE. 415 

work on the relation of micro-organisms to the disease has been 
accomplished. 

The experimental work of Koch, although it is confined en- 
tirely to animals, is of sufficient value to be recorded here. 

In Koch's experiments on septicaemia in mice he found in certain cases, 
in the neighborhood of the place of injection, in addition to the septicaemia 
bacillus, a micrococcus growth which produced a disease resembling gan- 
grene. By using field-mice instead of house-mice he was enabled to elimi- 
nate the bacillus, as this organism would not grow in the blood of the former 
animal. The micrococcus growth, however, developed at the point of inocu- 
lation just as well in field-mice as in house-mice. He found the ear of the 
mouse the best place to study the influence of the coccus upon the tissues 
and its mode of growth. He says: " Spreading out from the place of inocu- 
lation one can see extremely delicate and regular micrococcus chains, here 
pressed together so as to form thick masses, there arranged diffusely, the 
individual elements of these chains, as can be understood from the measure- 
ments of the longer ones, having a diameter of 0.5//." These organisms can 
be traced all through the gangrenous portions of the ear ; here neither red 
blood-corpuscles nor nuclei of lymph- or of connective-tissue cells can be 
seen. Even the exceedingly resistant cartilage-cells are pale and unrecog- 
nizable. "All the constituents of the tissues look as if they had been treated 
with caustic potash: they are dead, they have become gangrenous. Under 
these circumstances the bacteria develop all the more vigorously, the micro- 
cocci penetrate in numbers into the damaged blood- and lymphatic vessels, 
and here and there the cocci fill the vessels so completely that they appear as 
if injected." Just beyond the point reached by the cocci is a densely agglom- 
erated mass of nuclei, forming a wall, as it were, against the invasion of the 
micrococci. This wall has no great breadth, and immediately beyond it 
comes the normal tissue. The micrococci do not quite reach up to this layer 
of leucocytes. Between the two there is a layer of considerable breadth con- 
sisting only of gangrenous tissue, in which neither micrococci nor leucocytes 
are found ; the cells of the layer of leucocytes adjoining this gangrenous tis- 
sue appear to be in a state of disintegration. Koch thinks that the organisms 
excrete a soluble substance which comes in contact with the surrounding tis- 
sues by diffusion. When greatly concentrated this product has such a dele- 
terious action on the cells of the tissues that they perish. [A sort of coagu- 
lation-necrosis evidently takes place.] At a greater distance from the micro- 
cocci the poison becomes more diluted and acts less intensely, only producing 
inflammation. "Thus it happens that the micrococci are always found in 
the gangrenous tissue, and that in extending they are preceded by a wall 
of nuclei which constantly melts down on the side directed toward them, 
while on the opposite side it is as constantly renewed by lymph-corpuscles 
deposited afresh." 

The close resemblance between the membrane of diphtheria and 
certain forms of hospital gangrene has raised the question of the 
identity of the two diseases. The diphtheritic inflammations, how- 
ever, do not necessarily have any connection with the infectious 



41 6 SURGICAL PATHOLOGY AND THERAPEUTICS. 

disease known as " diphtheria." The diphtheritic membrane, such 
as is seen on mucous membranes or elsewhere, is due to a combina- 
tion of necrosis and inflammation. It is an anatomical process 
which may be caused by the Klebs-L,6frler bacillus, the organism 
that produces true diphtheria, or by the streptococcus, and possibly 
by other organisms. The action of the diphtheria bacillus is quite 
superficial, and it does not show a tendency to invade the deeper 
tissues. The presence of a diphtheritic membrane on an open 
wound does not therefore necessarily imply true diphtheria. The 
presence of streptococci in all other forms of membranous inflam- 
mations is a possible indication of what may be found in the diph- 
theritic form of hospital gangrene. 

The latest microscopical studies of specimens of gangrene, taken 
from the recently-dead subject, are those of Heine, made probably 
about 1870 — a period when little was known of the proper methods 
of bacteriological research. Sections examined with high powers 
of the microscope showed on the surface a finely granular homo- 
geneous layer, varying greatly in thickness, which contained large 
numbers of chain-like organisms resembling " those described bv 
some authors as micrococci. n These organisms were seen some- 
times in many-branched chains and sometimes in masses closely 
packed together. In the deeper portions of this layer were seen 
fragments of leucocytes (Eiterzelleii), and deeper still were found 
masses of leucocytes closely packed together, the same organisms 
being found either in the cells or in chains intertwined between 
them. Wherever the leucocytes had broken down the micrococci 
were more visible. In this layer was also seen a fine network of 
fibres which at places were continuous with broad bands of coagu- 
lated fibrin running between the cells. Lower still he found a 
layer of granulation tissue rich in blood-vessels, in many of which 
coagulation of the blood had taken place. In places the walls of 
the vessels appeared to have broken down, and they were sur- 
rounded by circumscribed clots or by diffused infiltration of the 
surrounding parts with blood. The tissues near the wound ap- 
peared to be infiltrated for a considerable distance with leucocytes 
which were collected between the fat-cells, the muscular fibres, and 
the tendons, so that these structures were fairly buried in the infil- 
trating tissue, and their nuclei appeared to be undergoing a degen- 
eration (coagulation-necrosis). The principal conditions observed 
by Heine were the larger numbers of micro-organisms, the marked 
tendency to coagulation of the intercellular substance and exuda- 
tion fluids, the enormous accumulation of leucocytes, and the 



HOSPITAL GANGRENE. 417 

tendency to degeneration of the cells and coagulated intercellular 
substance in the final putrefactive changes. 

The latest article on hospital gangrene is by Rosenbach. A 
careful study of two specimens sent to him from the Army Medical 
Museum at Washington showed that the preparations, preserved 
since the Civil War, were too old to make it possible to detect the 
presence of bacteria. Rosenbach reports in his earlier monograph 
two cases of traumatic gangrene in which the disease originated in 
a slight injury to the finger. Rapidly-spreading gangrene of the 
arm followed, and cultures taken from incisions made into the gan- 
grenous portions showed the presence of the streptococci. In two 
cases of traumatic gangrene, with emphysema, of a most malig- 
nant type he was able to find, microscopically, a bacillus, but no 
streptococci. The cultures failed. 

The writer mentions the following cases of traumatic gangrene — 
although clinically the disease is widely different from hospital gan- 
grene — because they have a bearing upon a personal experience: 

In 1883 the writer was summoned into the country to a case of traumatic 
gangrene following a gunshot injury of the leg. The disease had in forty- 
eight hours spread from the foot to the middle of the thigh, and the odor 
showed that putrefactive changes were well advanced. The operation of 
amputation in the upper third was performed at midnight. Proceeding on 
his journey the next morning, the writer met a physician in consultation 
in the afternoon, and explored a sinus communicating with a carious rib. 
A few days later a well-defined type of hospital gangrene was developed in 
the wound, which was not larger than would admit a good-sized drainage- 
tube, and before the disease could be checked an ulcer the size of a dessert- 
plate had formed. The only instrument employed in both operations was a 
pair of scissors, as, with this exception, the instruments of his colleague 
were used in the second operation. The scissors were employed to lay open 
the sinus where gangrene subsequently supervened. That they were the 
vehicle by which bacteria were transferred from one case to the other seems 
highly probable. 

So far as the evidence goes, it would seem to favor strongly the 
assumption of a streptococcus bearing the same relations to gangrene 
that the streptococcus erysipelatis does to erysipelas. But the bac- 
teriology of gangrene, after all has been said, from a modern point 
of view may still be regarded as almost a terra incognita. 

As has already been explained, the disease is not confined to 
hospitals, but may occur in private practice. The records of 
nearly all hospital epidemics show that many of the cases were 
brought into the hospital with well-developed gangrene. At the 
present time it is much more likely to be met with outside the 
hospital, where antiseptic surgery has no control. Why cases are 

27 



41 8 SURGICAL PATHOLOGY AND THERAPEUTICS. 

not brought into hospitals is a difficult question to answer. None 
are reported, although probably such occurrences do happen. It 
might be assumed that no epidemics exist at present, but with the 
present knowledge it is known that such surgical epidemics take 
their origin from favorable combinations of bad weather, filth, and 
crowded quarters. These combinations are not so difficult to 
obtain in every large city as to make the origin of sporadic cases 
of gangrene impossible. 

The presence of extra-mural cases of gangrene in the city during 
a hospital epidemic may be accounted for by contagion, for the 
route which the virus takes is often a very circuitous one. An 
example of this is given by Brugmanns, who states that in 1799 a 
quantity of charpie was sent from France for use in the Dutch 
hospitals. Wherever these dressings were used gangrene occurred. 
Inquiry brought out the fact that the charpie had already been used 
for dressing wounds, and that it had been cleansed and bleached for 
the trade. 

Much has been said about the contagiousness of gangrene. 
Medical literature contains too many examples of successful inocu- 
lation from man to animals and from man to man for the question 
to admit of any doubt. 

Joseph Jones experimented upon a large pointer dog: about half 
an ounce of gangrenous matter was taken from the wound of a 
dead subject and was buried between the lips of an incision. The 
wound subsequently took on a typically gangrenous condition. 
Fischer made wounds in five rabbits and rubbed into the wounds 
the discharges from a gangrenous wound. In all cases gangrenous 
ulcers were produced. Dussaussoy treated an ulcerated carcinoma 
of the breast in a man fifty years of age with inoculation of gan- 
grenous matter, the patient having refused to submit to the actual 
cautery. He dressed the sore for several days with charpie soaked 
in the gangrenous discharges, but without effect. He then decided 
to bruise the granulations and make them bleed, and then applied 
the matter to the freshly-made wounds, and in three days the ulcer 
had become gangrenous. This coincides with clinical observation 
that fresh wounds are more susceptible to the disease than those 
that are suppurating freely. 

Ollivier in 1810 had his arm inoculated with gangrene during an 
epidemic in Spain. He visited for this purpose a locality where 
the disease existed. The matter was taken from the wound of a 
young soldier who finally died of the disease. It was inoculated 
with a lancet into the skin of the deltoid region, after which 



HOSPITAL GANGRENE. 419 

Ollivier immediately returned home, distant a two-days' journey 
on horseback. Gangrene established itself in the puncture, and 
could only be controlled by the actual cautery. 

The following is an example of contagion from patient to 
patient reported by Act. Asst. Surg. Cleveland: 

In the officers' hospital an officer with gangrene occupied a room alone. 
The carpenters wished to put in a water-pipe, and he was removed to a room 
in which were three other officers with wounds not then gangrenous. 
All four had their wounds exposed and dressed, and the gangrenous odor 
pervaded the apartment. Although the officer was returned to his own room 
in an hour, the next day gangrene appeared in the wounds of the other 
three who had been exposed to the infection. 

Many clinical observations are cited where cases in hospital 
wards have not communicated the disease to patients with wounds 
in the adjoining beds, while patients in distant parts of the ward 
were attacked. This inoculation can easily be explained by trans- 
portation of the virus by dressers and attendants. More difficult to 
explain, however, is the existence of two wounds in the same indi- 
vidual, one of the wounds being gangrenous, the other being 
healthy. 

Asst. Surgeon Thomson reports the case of a soldier wounded by a frag- 
ment of shell which passed across the right thigh below Poupart's liga- 
ment, through the scrotum, destroying the right testicle, and behind the 
left thigh. The thigh-wounds were both superficial. The wound in the 
left thigh was attacked with gangrene. At this time there was in the right 
thigh a granulating surface, three by two inches in dimensions, level with 
the integument and cicatrizing rapidly. A smaller equally healthy surface 
remained unhealed upon the scrotum. The gangrenous ulcer continued to 
spread until it had involved the perineum and was eight inches in diameter, 
when it was finally controlled by treatment. In spite of the profuse dis- 
charge, the other wounds continued to cicatrize rapidly. Surgeon Thomson 
remarks: "If, therefore, the disease be propagated by inoculation, all the 
circumstances were favorable, since the proximity of the thighs at their 
upper part and a denuded surface on the scrotum, that might act as a link, 
render it certain that a portion of the great discharge from the left must fre- 
quently have been placed in contact with both of the other sores." 

Such a case seems not difficult to explain on the theory of the 
protective influence of the granulations. A bruising of the sore 
on the posterior aspect of the body led to its inoculation from some 
outside source. The healthy state of the granulations of the other 
wounds served as a protection to them. Probably most examples 
of this sort, when analyzed, can be explained in some such way. 
They were usually made to serve as an illustration of the theory 
that hospital gangrene is a "constitutional disease;" that is, a 
disease not due to local contagion. 



420 SURGICAL PATHOLOGY AND THERAPEUTICS. 

The question of the possibility of inoculation through the 
uninjured skin has been raised by Rosenbach, who points to 
Garre's experience with the inunction of cultures of the staphy- 
lococcus pyogenes aureus on the sound skin (p. 138). Very slight 
bruises are sufficient, as has already been seen. Gangrene is said 
to have occurred in the days of slavery after the use of the lash. 
Jones states: l ' Gangrenous spots followed by rapid destruction of 
tissue appeared in some cases in which there had been no pre- 
viously existing wound or abrasion." It is not probable, how- 
ever, that clinically gangrene is found developing in the unin- 
jured skin. 

. That meteorological influences favor the outbreak of an epi- 
demic of gangrene need hardly be said after the testimony of 
Macleod, of Keen, and of others already quoted. 

The hot sirocco was always dreaded at Scutari, and the peculiar 
climate at Andersonville had undoubtedly much to do with the 
progress and virulence of the epidemic. The heat of a camp 
exposed to the full rays of a summer sun in Georgia, and the 
heavy rains of that region, combined to favor the growth of a 
bacterial poison. In the North the sudden advent of cold and 
stormy weather is frequently noted as immediately preceding 
an epidemic. 

The period of incubation does not appear to be of certain dura- 
tion. The observation of Cleveland quoted above would place it 
at as short a period as twenty-four hours. Rochard cites a case 
where one week is supposed to have elapsed between the perform- 
ance of an operation with an infected instrument and the outbreak 
of the disease. In Ollivier's case of inoculation of his arm with 
the virus the characteristic appearances showed themselves first on 
the third day. 

The principal forms which are described by modern authorities 
are the ulcerating and pulpy forms. The term "diphtheria of 
wounds" is also frequently used to denote a milder type which 
appears to affect the granulations only. Some regard this simply 
as a milder form of ulcerating or " phagsedenic " gangrene; others 
are opposed altogether to the use of the term " diphtheria " in con- 
nection with gangrene, as the two diseases should not thus be con- 
fused with each other, they being two entirely distinct affections. 
Heine takes strong ground in favor of the identity of the two dis- 
eases. He bases his views partly on the frequent occurrence of 
diphtheria of the throat during epidemics of gangrene, and of 
cases of diphtheria following the reception of gangrene into hos- 



HOSPITAL GANGRENE. 421 

pital wards. During an epidemic at Heidelberg, Heine dressed 
the wounds for several weeks, during which time he had not seen 
a case of diphtheria. At the end of a month he was taken ill with 
diphtheria. During Heine's illness O. Weber, the noted surgical 
pathologist, took charge of his cases, and a few weeks later he 
also was attacked with diphtheria, which terminated fatally, 
although he had not previously been exposed to the disease. 
The present knowledge of diphtheria would enable one to deter- 
mine in a similar case whether the disease was a form of infection 
with the Klebs-Loffler bacillus, or, what is more probable, was a 
mixed infection of other organisms. 

A strong argument against the identity of the two affections 
is the alleged absence of paralytic symptoms following gangrene. 
Heine explains this by the relative nearness of the throat inflam- 
mation to the base of the skull, and by the ease with which such 
inflammation would extend to the nerves usually affected. Rosen- 
bach thinks that this paralysis is not produced in this way — that 
from the present standpoint of our knowledge the paralytic phe- 
nomena must be regarded as the result of a ptomaine-poisoning, 
and that the absence of such symptoms in gangrene implies the 
action of a different virus. Heine quotes, however, certain cases 
of gangrene where symptoms of paralysis have actually occurred, 
but his opponent regards these cases as not genuine gangrene, but 
as diphtheria of the wound. Felix inoculated wounds with the 
poison of diphtheria by dressing granulating wounds with charpie 
impregnated with fragments of membrane and secretions from cases 
of diphtheria. In two cases diphtheritic inflammation of the wound, 
of a moderate degree of severity, was produced. It is not denied 
that gangrene may not affect the mucous membranes, but it is 
claimed that in such cases the deep ulcerations and the charac- 
teristic conditions of the surrounding parts present a very dif- 
ferent appearance from ordinary diphtheria. 

Finally, the prevalence of diphtheria for nearly a score of years 
since the disappearance of gangrene is strongly suggestive of a radi- 
cal difference in the exciting causes of the two diseases, and, inas- 
much as it is known that a diphtheritic membrane can be formed 
by organisms which bear no relation to true diphtheria, there is 
now but little evidence to produce in favor of their identity. 

In the mean time, guided by clinical appearances only, it will be 
best to distinguish a diphtheritic form of gangrene. This form may 
be regarded as the mildest type of the disease, and as one in which 
the granulations are chiefly affected, and in which there is an arrest 



422 SURGICAL PATHOLOGY AND THERAPEUTICS. 

of the healing process rather than destruction and enlargement of 
the area of the wound. The earliest change to be noted — and one 
which, in the writer's student days, the dresser was cautioned 
always to watch for carefully in every case — was a change of the 
granulations from their healthy red color to a grayish tint. There 
is at first a loss of color. The surface of the wound becomes glazed 
and somewhat opaque, forming a thin veil or membrane through 
which the contour of the granulations is still seen. The increasing 
opacity and thickness of this layer finally forms a sort of u rind," 
which occasionally develops without any accompanying symptoms 
of infective inflammation. This membranous condition of the 
wound may be caused by some accidental source of irritation, 
such as the retention of foul discharges, mechanical irritation, or 
the presence of a foreign body in a fistulous canal opening into the 
wound. What has occurred is chiefly a change in the character of 
the discharge from the wound with coagulation of the exudation on 
the surface. When, however, the disturbance in the healing pro- 
cess is more profound, as shown in alteration of the granulation 
tissue with distinct increase of irritation in all parts of the wound, 
in greater readiness on the part of the granulations to bleed, and 
in a more inflamed appearance of the margins of the wound, the 
surgeon may look for coagulation-necrosis involving the upper 
layer of the granulations, and consequently the development of 
a diphtheritic membrane. This membrane may involve a depth 
of tissue sufficient to produce necrosis of the surface to a con- 
siderable extent and the formation of sloughs, or there may be 
seen here and there small extravasations of blood due to the 
breaking down of the walls of the vessel which supplies the dif- 
ferent granulations. 

The secretion of the wound is at first diminished; later it 
changes in character and becomes more watery, and it is then 
much more abundant, so that in some cases the dressings become 
quickly saturated with the discharge and require to be changed 
frequently. The margins of the wound are not materially affected 
in the milder cases, but when the granulating surface becomes 
more deeply infected the edges of the ulcer are found thickened 
and raised, while at the same time portions of the membrane melt 
down or are thrown off as small sloughs. The wound assumes a 
crater-like appearance, and occasionally the edges of the skin 
begin to break down and have an appearance as if they had been 
gnawed by some rodent. Usually the process is arrested by treat- 
ment, and as the membrane melts away or is cast off the healthy 



HOSPITAL GANGRENE. 423 

granulations appear, and the swollen and somewhat injected lips of 
the wound resume their natural size and color, the cicatrizing pro- 
cess proceeding once more. 

The type to be placed next in point of severity, but which 
writers generally regard as less frequent than either of the 
other varieties, is the ulcerating form. Here the formation of a 
membrane is not so apparent: the granulations, however, have an 
unhealthy appearance, are paler than usual, and have lost their 
plump, exuberant character. On closer inspection it is found that 
a number of them are the seat of minute dark-red or light-gray 
patches, which are sprinkled about over the surface of portions of 
the wound. These points soon break down and leave behind them 
clean-cut circular excavations in each granulation. Some of these 
patches look like small pustules, which, when they break, expose 
a grayish surface. These minute ulcerations subsequently run 
together and form an ulcer in the granulating surface. Several 
such ulcerations may develop in different portions of the wound, 
and when the process has extended to the outer border, the skin 
becomes involved and breaks down, leaving semi-circular defects 
which give the lips of the wound the appearance of having been 
bitten out. At this time the surface of the wound becomes dis- 
colored and assumes a grayish or a brownish hue, the discharge 
becoming thin and streaked with blood and having a foul odor. 
The process is not usually a rapid one, and the breaking down and 
enlargement of the wound may be an affair of several weeks. In 
this way the wound may increase in size indefinitely both in area 
and in depth. The extent to which the ulcerating process will 
penetrate depends somewhat upon the anatomical nature of the 
tissues. A dense fascia will exert a limiting influence, but when 
loose connective tissue is involved muscles may be dissected out or 
be eaten through. In the case reported by Thomson, already 
quoted, the condition of a wound of the posterior portion of the 
thigh is thus described: 

" An ulcer three by two inches in extent was found, oval in shape, covered 
with an ashy-gray slough upon its margin, thickened and everted, surrounded 
by a livid areola, and, instead of normal pus, discharging a thin fetid serum 
mixed with debris." This description portrays fairly well the diphtheritic 
type. Attempts to treat it with applications of nitric acid were unsuccess- 
ful, and the report continues : 

"There was the characteristic margin preceded by the areola of livid 
stasis preparing the tissues for their rapid destruction. The connective tis- 
sue beneath the skin had been destroyed, so that the skin for an inch from its 
margin was perfectly movable. The muscles, separated from each other by 



424 SURGICAL PATHOLOGY AND THERAPEUTICS. 

the death of their connective tissue, lay in the wound, bathed in its discharge, 
but rosy and florid and resisting the advance of the disease. This sore was 
so unmistakably hospital gangrene that several pictures of it were taken by 
direction of Surgeon Bristow, which represent well the surface of the ulcer 
dripping with its thin, serous discharge, mingled with threads of dead con- 
nective tissue, its ' piled-up,' thickened, and everted margin surmounted by 
a thin line of vivid redness, and its broad zone of purple congestion shading 
away into a bronze hue, the depth of color in the areola indicating the en- 
gorgement of the small vessels, and its hue the feebleness and slowness of 

the movement of the blood But little change had taken place in the 

character of the ulcer, which was eight inches in length by seven in breadth, 
extending to the perineum and irregularly oval in shape. The muscles 
exposed (the semimembranosus and biceps) had yielded, and were now 
almost divided. ' ' The interval of time which had elapsed during which the 
changes described had taken place was a little over two months ; from this 
time on convalescence took place. 

A case like this may be regarded as a somewhat severe example 
of the ulcerating form, but the appearances of the skin around the 
wound are such as are to be expected when the ulcerating type has 
reached its full degree of development. Frequently, however, the 
disease is confined to a superficial form of ulceration, and then 
there would be seen but little sloughing or membrane-formation. 
The wound has a dirty, unhealthy, or sometimes only an irritated 
look, and is constantly growing larger until arrested by treatment. 
The different phases of phagsedena are well portrayed by this type 
of gangrene. 

The striking results of phagsedenic ulceration are well shown 
by Plate xxvii. of the Surgical History of the War of the Rebellion, 
where a portion of the calf of the leg has been eaten to the bone, 
laying bare the popliteal artery at its lowest portion. The wound 
looks as if it had been produced by the teeth of some wild animal. 

These examples are, however, suggestive of those forms which 
may be said to come between the ulcerating form and the character- 
istic and commonest type of hospital gangrene — " the pulpy form." 
This variety includes all the graver cases with extensive and deep- 
seated loss of tissue. 

The pulpy form may begin with a diphtheritic infiltration of 
the granulations, which infiltration rapidly swells to a thick and 
cedematous covering of the wound, or the color of the granulations 
deepens, owing to an intense hyperemia of the part. Under the 
increased blood-pressure many of the tender walls of the blood- 
vessels give way and diffuse extravasations take place, or, as Piro- 
goff describes, hsematomata may form rapidly, owing to profuse bleed- 
ing in the granulation tissue at certain spots. This form is some- 






HOSPITAL GANGRENE. 425 

times called the " hemorrhagic.' ' Whatever the preliminary 
changes may be, the surface of the wound soon becomes enor- 
mously swollen, and it is changed into a dirty gray or a greenish 
mass of putrefying sponge-like tissue. The secretion of the wound, 
which was at first arrested, now begins to run again. It wells up 
through the pulpy mass in the form of fetid ichor, the odor of 
which is thought by many to be quite characteristic. The edges 
of the wound become extremely sensitive, and they are everted and 
raised and of a deep-red or purple tint, shading off, when the dis- 
ease is spreading, into a bronzed hue. Changes as profound as 
these may occur within from twenty-four to forty-eight hours. 
The swollen membrane thus formed soon begins to putrefy, but it 
does not readily separate. Its color changes frequently, and it is 
difficult to describe. It is often distended with gas from the 
decomposing substance, and it finally breaks up into soft, gelatin- 
ous sloughs or moist, cheesy debris, and is thrown off, only to be 
followed by new formations beneath it. In the mean time the 
deeper tissues have been attacked, and the advance of the infec- 
tion is indicated by the increased amount of inflammatory reaction, 
as shown by the great swelling, the discoloration of the surround- 
ing integuments, and the profound constitutional disturbance. At 
this time secondary hemorrhage from some large vessel frequently 
takes place, speedily terminating the case fatally or necessitating 
the ligature of the femoral or brachial or other vessel of largest 
size, thus involving the formation of a wound in which gangrene 
may develop itself anew. The changes described are taken from 
personal memory of cases which occurred in the epidemic of the 
hospital to which reference has already been made. 

The differences that may occur in the form of the exudation are 
of course very great, each epidemic showing peculiarities of its own. 
Rosenbach describes a gelatinous membrane which occasionally 
forms enormous colloid vegetations. When in a state of putre- 
faction such voluminous masses have been likened to decomposing 
foetal brains. 

The discharge from the wound is enormous; it may be orange- 
colored or may be brownish, or — what is a more generally fitting 
description — it may be foul and dirty. Pitha says of it: " No mat- 
ter how deep the infiltrated surface appears to be, it always seems 

insufficient to account for the great quantity of the discharges 

The foul pus pours in such cases as if it came from an inexhaust- 
ible spring. ' ' 

As the infection advances no tissues are spared: the muscles are 



426 SURGICAL PATHOLOGY AND THERAPEUTICS. 

laid bare, and they often so swell and soften, as they are rapidly 
eaten through, as to suggest the presence of a sloughing sarcoma. 
The nerves are dissected out, but they generally retain their ana- 
tomical form and distribution. The fasciae are more resistant, but 
they do not long resist the advance of these graver types of the dis- 
ease. Articulations may be laid open, and even the bones may not 
escape necrosis. In some of the most malignant types the greater 
portion of a limb may thus become disorganized, but these cases, 
fortunately, are rare. The skin has a marble hue, the parts are 
distended by emphysema of the connective tissue, and mortifica- 
tion of the limb may ensue. 

The great swelling which takes place in the different layers of 
the wound is often deceptive as to the amount of tissue which has 
been lost. This is shown after the membrane separates and the 
wound rapidly contracts. 

The disease does not always advance with the rapidity indicated. 
Even cases which eventually may terminate fatally may begin and 
advance with great deliberation until, as the vital powers become 
lowered, the gangrene seems to gain new strength and to assume a 
more malignant type. 

The early writers generally state that at first constitutional 
symptoms are wanting, but this is probably due to the fact that 
thermometric observations were not taken. It is not, however, 
until the second week that the symptoms become marked. The 
fever-curve is of course variable, corresponding more or less with 
the local manifestations. It is. quite irregular — more, as Heine 
says, like an outline of the Alps. The constitutional symptoms 
are probably produced by the absorption of the toxic products, or 
possibly by the bacteria themselves, and the fever does not differ 
clinically from that of septicaemia. But, although the typhoid- 
like condition with diarrhoea is characteristic of both affections, in 
gangrene there is a marked clinical feature in the great sensitive- 
ness of the wound. The pain and nervousness attending the dress- 
ing of the wound are such, in some cases, that few men possess the 
fortitude to go through the ordeal. The bare idea of a change of 
the dressing may bring on, according to Pitha (whose patients were 
probably Southern Germans), convulsive trembling, perspiration, 
and palpitation of the heart. It is often necessary to etherize the 
patient at these times, especially when escharotics are applied. It 
is not surprising that many cases are followed by relapse, or that 
patients who have been discharged from the hospital as apparently 
cured have returned with the disease in full bloom again. Such a 



HOSPITAL GANGRENE. 427 

reinfection could easily take place from germs concealed in some 
part of the patient's person. 

Among the most frequent complications of the disease is ery- 
sipelas; and if it may be supposed that they are both caused by the 
streptococcus group of organisms, it is certainly not surprising. 
With such a severe infective form of inflammation as gangrene, it 
is also to be expected that pyaemia may occasionally be met with, 
but this complication would probably not supervene unless local 
phlegmonous inflammations had followed or complicated the origi- 
nal disease. 

A few selected cases may perhaps give a clearer idea of the cause 
and peculiarities of the pulpy form of gangrene: 

Thomson reports a case of amputation of the thigh for a fracture of the 
tibia caused by a Minie-ball at the battle of Fredericksburg. The wound 
had healed, except a narrow strip of skin, on February 18, when it was found 
covered with a gray slough and had the characteristic odor. The cicatricial 
tissue soon yielded to the sloughing, and the subcutaneous connective tissue 
had been destroyed for two inches beneath the skin at the outer angles of the 
original incisions. The destruction was limited to the connective tissue 
until the nineteenth day, when the skin became involved. The constitu- 
tional symptoms became grave; the mental despondency was marked; a free 
diarrhoea also began. The whole surface of the stump had now a margin of 
black mortification of the skin, outside which was the usual areola of purple 
congestion, the complete stasis of to-day becoming the sphacelus of to-mor- 
row. The end of the femur, protected by rosy granulations, now protruded 
from the black mass of sphacelus, the integument having become loosened 
by the destruction of the subcutaneous connective tissue, and retracted. The 
presence of this mass of putrefaction seemed to add to the nervous prostra- 
tion, if, indeed, the absorption of such peccant material is not its sole cause. 
On the thirty-first day the symptoms had been typhoidal for several days: 
emaciation had gone on rapidly; there had been subsultus tendinum and 
muttering delirium with extreme prostration until this date, when death 
occurred. The limb was removed after death, and the specimen sent to the 
Army Medical Museum (Specimen 1000, Surg. Sect.). The sphacelus had 
involved all the tissue for five inches above the divided bone, and there 
seems to have been a faint effort to form a line of demarcation. 

An interesting point illustrated by this case is the presence of 
healthy granulations at the end of the bone in the centre of the 
gangrenous mass. This is a peculiarity noticed by many writers 
— namely, that a portion of a wound may be affected with the dis- 
ease, and in another part the granulations may be in a perfectly 
healthy condition. Jones reports a large number of cases in great 
detail. The following case is illustrated by two colored plates: 

A man twenty-two years of age, who had been in the Confederate service 
nearly four years, was wounded in the middle of the left thigh (Aug. 17, 



428 SURGICAL PATHOLOGY AND THERAPEUTICS. 

1864) by a piece of lead, weighing about a pound, from a rifle-shell. He was 
removed from Atlanta to Macon, and the disease appeared four days after 
his arrival at the latter place. On the fourteenth day the wound in the 
thigh was eight inches in diameter, was nearly circular, and was deeply 
and irregularly excavated; the edges were everted and the surface was 
coated with a dirty grayish, purplish, and dark-bluish leaden-colored laver. 
There was a most fetid, irritating, and sanious discharge from the wound, 
but no pus. Temperature 105. 6° F. The next day the large muscles of 
the thigh were exposed by the gangrenous excavation, and they were fre- 
quently observed, quivering, especially after the application of nitric acid, 
which causes intense pain. On the twenty-fifth day the wound began to 
assume a healthy appearance, and on the thirty-fifth day it was cicatrizing. 

The next case, which is an example of the ability of gangrene 
to lay open joints, is quoted from the same author: 

The patient was thirty- seven years of age. A Minie-ball struck the 
flesh}- part of the forearm about the middle : no bones were injured. This 
injury- occurred July 20, 1S64, the patient being transferred from Atlanta to 
Macon. At the end of a month, when the wound was healing, it took on 
gangrenous inflammation, became swollen, and was surrounded by a red, 
livid areola and burned most painfully. By the middle of September the 
muscles of the arm and forearm in the region of the elbow-joint were 
extremely denuded and the gangrene was spreading. Application of nitric 
acid did not arrest it. October 1. the gangrene had denuded the condyles of 
the humerus and had penetrated the joint. The muscles exposed presented 
red, purplish, and greenish colors in different portions. The odor of the 
wound was insupportable. There were great prostration, dejection, and 
nervousness with muttering delirium. Tongue was dry and of a dark pur- 
ple-and-blue color. October 4. hemorrhage from the brachial artery, near 
where it divides, took place at sunrise, and the patient died in twenty 
minutes. 

Dr. Jones dwells upon the sallow hue of the complexion and the 
livid-blue color of the tongue as derangements manifestly induced 
by the gangrenous poison on the constitution of the blood. Per- 
haps the most striking examples of the severest type of the disease 
are related by Macleod: 

" In the Crimea, during the summer of 1S55, after the taking of the quar- 
ries and the assault in June on the Great Redan, not a few cases of amputa- 
tion of the thigh were lo?t from moist gangrene of a most rapid and fatal 
form. In the case of a few. who lived long enough for the full development 
of the disease, gangrene in its most marked features became established, but 
most of the men expired previous to any sphacelus of the part, overwhelmed 
by the violent poison which seemed to pervade and destroy the whole 
economy." 

Two cases under Macleod' s own care, in men who had a limb utterly 
destroyed by round-shot or by grape, are thus described : ' ' During the night 
previous to death the patient was restless, but did not complain of any par- 
ticular uneasiness. At the morning visit the expression appeared unaccount- 



HOSPITAL GANGRENE. 4^9 

ably anxious and the pulse was slightly raised. The skin was moist and the 
tongue clean. By this time the stump felt, as the patient expressed it, heavy 
like lead, and the burning, stinging pain had begun to shoot through it. On 
removing the dressings the stump was found slightly swollen, and the dis- 
charge had become thin, gleety, colored with blood, and having masses of 
matter like gruel occasionally mixed with it. A few hours afterward the 
limb became greatly swollen, the skin tense and white, and marked along 
its surface by prominent blue veins. The cut edges of the stump looked like 
pork. Acute pain was felt. The constitution had by this time begun to 
sympathize. A cold sweat covered the body, the stomach was irritable, and 
the pulse was weak and frequent. The respiration became short and hurried, 
giving evidence of the great oppression of which the patient so much com- 
plained. The heart's action gradually and surely got weaker till, from four- 
teen to sixteen hours from the first bad symptom, death relieved his suf- 
ferings." 

In regard to the pathological anatomy of the disease little 
remains to be said. The post-mortem appearances are those which 
are the result of septicaemia, unless pyaemia has occurred as a com- 
plication. In this case it is probable that in trie neighborhood of 
the wound there would be evidence of phlegmonous inflammation. 

One would hardly suppose that there would be any difficulty in 
the diagnosis of the disease, yet in its early stages there are con- 
ditions of hospital wounds which might be mistaken for gangrene. 

The mechanical or the chemical irritation of the granulations may 
be the result of unsuitable dressings, such as were frequently applied 
in former times. There may be obtained in this way capillary 
hemorrhage with oedema of the granulations, and even the forma- 
tion of a croup-like layer. The writer has at the time of this 
writing a wound of the bursa of the elbow that has assumed such 
an appearance from hardening of the secretions in the dressing, 
which had been kept on a week. The presence of a foreign body 
or of a piece of dead bone, especially if the sequestrum consist of 
a fragment of cancellated bone with decomposing matter retained 
in its meshes, may also cause doubtful appearances of the wound, 
and even the formation of a rind upon the surface of the granula- 
tions. Such a rind is not infrequently seen in feeble or in aged 
individuals, or it may be due to the presence of a scorbutic or tuber- 
culous taint in the tissues or in the system. Occasionally bed- 
sores will counterfeit closely the appearances of hospital gangrene 
in the spreading of the wounded surface and in its sloughing con- 
dition. The writer has seen carbuncular sloughs transform a 
wound into one of this appearance, and show a tendency to spread 
which could only be checked by thoroughly cleansing and disin- 
fecting the wound. This condition occurred in a feeble old man. 



430 SURGICAL PATHOLOGY AND THERAPEUTICS. 

The ' ' gray look ' ' of a wound which has hitherto been healing 
kindly must be regarded as suspicious, particularly in times of epi- 
demics, and formerly it was a condition that was always regarded 
with great distrust. 

The prognosis of the disease is very variable. It must not be 
supposed from the clinical description given above that the mor- 
tality is greater than septicaemia, pyaemia, or tetanus, for instance. 
It is undoubtedly as serious a wound-disease as erysipelas, and per- 
haps more so, although such epidemics of erysipelas as occurred in 
America about fifty years ago have been of the gravest character. 
The ulcerating form is much less dangerous than the pulpy form, 
and the latter type varies greatly, according to its locality, in its 
effect upon the system. Penetration of the great cavities, such as 
the peritoneum or the pleura, by gangrenous ulceration is almost 
invariably followed, according to Packard, by a fatal termination. 
The opening of a joint during the progress of the disease cannot 
be regarded in any other light than as a most serious complication. 
In the epidemics observed since the beginning of the present cen- 
tury the mortality has varied from 18 to 80 per cent. In some of 
the more recent campaigns the mortality has probably been at a 
much lower figure. 

The number of cases of gangrene reported in the Surgical His- 
tory of the War of the Rebellion was 2642. Of these cases, 1142 
were fatal, making a mortality of 45.6 per cent. The percentage 
of fatality (with the exception of penetrating wounds of the trunk) 
of cases of gangrene after flesh-wounds was larger than that after 
fractures. In one of the more recent epidemics, which occurred in 
the barracks at Berlin, the mortality was only 6 per cent. 

In undertaking the treatjnent of hospital gangrene it is import- 
ant to remember that the agent employed must come directly in 
contact with the diseased tissue — that it will be of no avail to dress 
the wound simply with applications containing an efficacious drug. 
The dead portions on the surface must first be removed, the mem- 
brane be scraped away, and sinuses be laid open, in order that the 
remedy may be enabled to exert its influence directly upon the dis- 
eased part. It is pre-eminently a disease where heroic treatment 
is clearly indicated. 

The actual cautery has always been popular with the French 
surgeons. Pouteau was the first to endorse it. He says: u Cette 
pratique etait familiere aux anciens: osons la retablir dans tout son 
lustre." Rochard says: u The actual cautery is more terrifying 
than painful. At a white heat and passed rapidly over the tissues 



HOSPITAL GANGRENE. 43 1 

it is less painful than applications of perchloride of iron. The 
cautery may be followed by the use of cold compresses removed 
from time to time until the pain ceases." At the present time the 
most suitable dressing to follow this would be an antiseptic poul- 
tice frequently renewed and alternating with an antiseptic bath 
until the separation of the sloughs has taken place. 

Nitric acid in full strength, which has been much used, seems 
to have been the favorite application by Southern surgeons during 
the war. Jones advises a liberal and thorough application of the 
acid: "It should not merely coagulate and alter completely the 
gangrenous matters, but also come in contact with the sound 

parts In most cases one thorough application of the acid 

will be sufficient If, however, the patients be retained in 

the crowded wards or tents, the most energetic treatment will fail 
entirely of arresting the disease." 

The patient, as in the case of cautery, should be placed under 
the influence of an anaesthetic and all gangrenous tissues should 
carefully be cut away. All sinuses found under the skin or in the 
connective tissue should be laid open freely and the dead tissues be 
removed. As Keen says: "Stumps must be laid bare and appa- 
rently ruined; sinuses must be fully exposed and the disease 
relentlessly pursued to its farthest refuge." Rochard well adds: 
"II faut du courage." 

For milder cases an acid wash may be used consisting of solu- 
tions of hydrochloric acid of greater or lesser strength; the one 
in use for many years at the Massachusetts General Hospital 
during epidemics was the following: 



1^. Potass, chlor., 


3ss; 


Acid hydrochlor., 


3j; 


Misce et adde. 




Aquse, 


3vii 



It can be applied on charpie. 

Keen used chiefly in the West Philadelphia epidemic the acid 
nitrate of mercury, preferring it to nitric acid, as it caused less 
pain and often saved time by enabling the surgeon to dispense 
with an anaesthetic: "The pain continues for a shorter time, the 
slough appears to be destroyed and disintegrated more thoroughly, 
and it separates in from twelve to thirty-six hours sooner than that 
from the acid." He continues: "The constitutional treatment is, 
I take it, of far less importance than the local, just as the consti- 



432 SURGICAL PATHOLOGY AND THERAPEUTICS. 

tutional symptoms are less grave than the local. Frequently they 
will subside entirely after the vigorous local treatment advocated. 
The fever will abate, the patient will sleep well, the tongue clean, 
the bowels relax, and he will tell you the next morning that he 
has eaten an excellent breakfast and 'feels first-rate.'" 

The 'application of pure or fuming bromine was advocated 
strongly by Goldsmith. This drug should be applied with great 
thoroughness. It at once obliterates all gangrenous odor; its 
ready vaporization permits its application to the bottom of the 
sinuses and sulci which cannot safely be laid open with the knife. 
Its action is almost instantaneous. Surgeon Cleveland was in 
the habit of applying bromine to all cuts or injuries of his fingers, 
and he had no trouble with such wounds, although coming into 
daily contact with the disease. Goldsmith advises for milder cases 
the following solution of bromine: 

i». 



Brominii, 


5; 


Potass, bromid., 


gr. 1 60; 


Aquae, 


ad 3iv.— M. 



Lint saturated with this solution should be applied to the part; 
over this a dry piece of lint; over this a sheet of lint spread with 
simple cerate; and outside of all a piece of oil-silk, which is 
intended to retain the vapor as long as possible. If the sloughs are 
thick and they cannot well be trimmed, the bromine may be intro- 
duced into the thickness of the slough by means of a hypodermic 
syringe. The irritating effects of the vapor of bromine upon the 
eyes and the air-passages of the dresser were such as to give a great 
deal of unpopularity to this remedy. It was employed, however, 
with great success in many of the army hospitals during the war, 
and afterward in civil practice, and those who had occasion to give 
it a fair trial were enthusiastic over its thorough work. 

The French used perchloride of iron in their last war with suc- 
cess; it was the most successful remedy at Brest. Charpie soaked 
with it should be applied to the cleansed wound, and be renewed 
at the end of every twenty-four hours for a longer or shorter 
period. Its application appears to have been quite as painful as 
that of the much more powerful remedies. 

Packard recommends the use of sugar — a carbohydrate not giv- 
ing up its oxygen — which prevents oxidation and which acts as a 
preservative. Powdered white sugar may thoroughly and thickly 
be dusted over the wound or be applied as a thick syrup. "The 



HOSPITAL GANGRENE. 433 

cure consists in the removal of all sloughing and dead tissues, and 
in opposing oxidation by means of a dressing with any substance 
which either contains no oxygen or will not give it up." 

At the present time the vast array of modern antiseptic reme- 
dies, among which we may mention iodoform and peroxide of 
hydrogen, will be at hand for the surgeon's use. Of these reme- 
dies, carbolic acid has already been employed in several epidemics. 
In weak solution it does not penetrate sufficiently deep. Heuter 
used 5 to 10 per cent, solutions, and reapplied them several times a 
day. In this shape it has a caustic action, but it was apparently 
not adapted to severe cases. It goes without saying that the most 
powerful prophylactic treatment is the application of the laws of 
strict asepsis so far as they can be carried out. If a single case 
occurs in a hospital ward, it should immediately be isolated; if a 
number of cases occur at once, the ward should be evacuated. An 
epidemic at the Chestnut Hill Hospital, near Philadelphia, was 
arrested in twelve hours by placing all those attacked with the 
disease in tents in an adjoining grove. A chronic case which has 
obstinately resisted local treatment will often improve rapidly after 
a complete change of room, of bedding, and of clothing. 

Amputation for hospital gangrene of stumps was a frequent 
resort in pre-antiseptic days. There is no doubt that the presence 
of gangrene is no contraindication to such an operation at the pres- 
ent time. With thorough antiseptic precautions the case ought to 
do well afterward. In 1870 such an attempt was made by a Ger- 
man surgeon for gangrene of the foot involving the tarsal joints. 
The wound was soaked with a strong solution of carbolic acid, and 
the foot was carefully wrapped up in cloths wet with the same solu- 
tion. The leg was thoroughly washed with " phenyle-water ' ' 
before the operation. The dressing for the stump consisted of 
carbolic compresses. The healing was slow at first, but after the 
opening of a small pus-cavity cicatrization rapidly took place. 

28 



XVIII. TETANUS. 

Tetanus (from TtTdivco, to bend) is an infectious disease, gen- 
erally traumatic in origin, characterized by painful tonic contrac- 
tion of the muscles, beginning with those of the jaw or the neck 
and affecting progressively the muscles of the trunk and the limbs. 
It is accompanied by convulsive paroxysms and an irritation or 
inflammation of the nerve-centres in the upper portions of the 
cord. It is due to the presence of a bacterial poison in the blood 
and tissues. 

The etiology of the disease has received a vast amount of study 
by modern as well as by ancient writers, and its origin has been 
attributed to various causes. One of the causes to which the dis- 
ease has most frequently been attributed are sudden changes in the 
weather, particularly change from heat to moist cold. After the 
battle of Prague there was said to be as many as a thousand cases 
of tetanus among the wounded who were left upon the field of bat- 
tle without shelter. In the Austrian campaign of 1866, Stromeyer 
saw thirteen cases after a cold storm which followed a period of 
heat. At Strasburg, Poncet did not see a single case of tetanus 
during the early period of the siege, but in September, after a 
sudden fall of the thermometer, a dozen cases occurred in the 
military hospital in which he was stationed. In tropical coun- 
tries the disease appears to be much commoner and to favor cer- 
tain regions. Negroes are supposed to be peculiarly susceptible, 
among whom, in Brazil and Peru, the disease is said to be very 
common. In Algeria the Arabians are supposed to enjoy an 
immunity to the disease; such at least is the experience of 
French surgeons. Idiopathic tetanus is said to be common in 
the Southern United States, in Central America, and in the 
West Indies: in Europe tetanus has most frequently been ob- 
served in connection with military surgery. 

It has also been supposed that the disease might originate from 
an injury to some nerve-trunk. One of the most acute and typical 
forms of tetanus under the writer's care followed a lacerated wound 
of the arm with exposure of the median nerve for several inches in 
its length, in a way that rendered it impossible to cover the nerve 

434 



TETANUS. 435 

with the integuments; but Weir Mitchell reports that tetanus from 
injury to the nerve-trunk occurred in only one case out of all that 
he observed during the late war, and he believes that the source of 
irritation is in the peripheral branches of the nerves in the majority 
of cases. Such a reflex origin of the disease has been assumed by 
several authorities, and the sometimes almost instantaneous relief 
of symptoms by the division of painful cicatrices or other sources 
of nerve-irritation gives ground for this belief. In the report of a 
case in the Surgical History of the War the symptoms were appar- 
ently due to such a cause, following amputation of the finger. 
Several months after there appeared tetanic symptoms, which 
were immediately relieved by the removal from the cicatrix of a 
neuroma about the size of a buckshot. The history of this case 
renders the diagnosis doubtful, but the association of the symp- 
toms with the peripheral irritation is at least suggestive. 

In another case, where the median nerve was caught in the 
cicatrix, intense pain was suffered and there was great nervous 
irritation after the wound had healed. Partial trismus occurred 
finally, that was somewhat relieved by an incision which freed the 
nerve from the cicatrix. The tetanic symptoms recurring were 
not relieved by resection of the nerve, and amputation was resorted 
to, after which the man recovered. Larrey divided certain cica- 
trices of the shoulder that gave rise to cramp-like pains and tetanus, 
the operation being followed by immediate relief of all the symp- 
toms. "The patient opened his mouth and was cured." Rose 
refers to such cases, which he calls u scar- tetanus. " 

Following out this idea, some writers thought that the situation 
of the wound played an important part in the origin of the disease, 
and an endeavor was made to establish the fact that it was as a 
complication of wounds of the hands and the feet that tetanus was 
almost invariably found; but examination of statistics shows that 
this view is not borne out by the facts of the case, that the disease 
may follow injury in almost any region of the body, and that it 
may arise spontaneously when no perceptible wound is to be found. 
The view that tetanus was of humoral origin has been advocated 
by Travers, Billroth, and others for a long time. This theory 
assumed an intoxication due to the formation of a poison de- 
veloped either in the wound or in the perspiration — in other 
words, a ptomaine. An attempt was not made, however, to 
associate this chemical product with the development of bac- 
teria. 

It was not until 1885 that the bacillus tetani was discovered. It 



43 6 SURGICAL PATHOLOGY AND THERAPEUTICS. 

is a long-, slender rod, in one end of which a spore forms, distending 
the cell into a "drumstick" shape (p. 54). It is one of the most 
marked types of anaerobic bacteria, and it is usually found min- 
gled with several other varieties, from which it has been separated 
with great difficulty. For this reason pure cultures have only quite 
recently been obtained. The organism is found principally in the 
tissues near the wound, and it has not been satisfactorily demon- 
strated in either the blood, the internal organs, or the central 
nervous system. Injected into animals after cultivation, the or- 
ganism produces symptoms of tetanus in twenty-four hours. At 
the autopsy a slight infiltration is seen at the point of injection, 
but no coarse changes are seen elsewhere. A few bacilli are 
found near the point of injection, but none in other parts of the 
body. In no case do their numbers stand in any proportion to 
the severity of the symptoms. For this reason it has been 
assumed that the organisms manufacture at the point of inocu- 
lation an extremely active poison which disseminates itself 
throughout the body. Betoli mentions the fact that slaves died 
of tetanus after having eaten the flesh of a bull which had per- 
ished from that affection. 

Brieger has, in fact, succeeded in obtaining from the culture of 
the bacteria ptomaine which he called ' ' tetanine. ' ' The same 
substance he also obtained from the freshly-amputated arm of a. 
man afflicted with the disease. 

Under what special conditions infection takes place in man 
cannot yet be stated with any certainty. The tetanus bacilli are 
found in large numbers in the world about us — in garden soil, in 
the dust and sweepings of our streets and dwellings, in crumbling 
masonry, in putrefying fluids, and in manure. In connection with 
the latter source it may be mentioned that French writers, and par- 
ticularly Verneuil, regarded persons who are brought in contact 
with horses as particularly susceptible. Considering the great 
numbers of tetanus bacilli that are constantly to be found about 
us, it might seem surprising that tetanus is so rare a disease. This 
is explained by their anaerobic nature. The presence of free oxygen 
prevents the development of the bacteria. The bacilli are there- 
fore unable to find an opportunity to grow upon small and super- 
ficial wounds except in rare instances. Punctured wounds lodge 
the organisms deep in the tissue, a soil better fitted for their growth. 
If the penetrating foreign body, such as a splinter or a nail, should 
carry in with it dirt from the skin, grains of sand, or fragments of 
stone, the conditions are peculiarly favorable for the inoculation. 



TETANUS. 437 

and development of the bacilli. Among the predisposing- causes 
of tetanus may be mentioned age. Yandell shows that the disease 
is peculiarly fatal to persons under ten years of age, and that this 
period included 7 per cent, of all the cases collected by him, but 
did not include trismus nascentium. The disease is said to be rare 
in later life, but the same author noted fifteen cases occurring in 
individuals over fifty years of age; and one case is reported in a 
man aged eighty-nine. The condition of the patient's health is an 
important factor in his ability to resist the inroads of the micro- 
organisms. The enormous number of cases reported after the 
battle of Prague, although doubtless greatly exaggerated, indi- 
cates that exhaustion and exposure produce an enfeebled vitality 
peculiarly favorable for the origin of tetanus. Doubtless meteor- 
ological conditions favor the growth of the bacillus of tetanus, and 
under certain combinations it can easily be imagined that the dis- 
ease might assume an epidemic form. Epidemics of the disease 
have not only been reported in literature, but it is probable also 
that every hospital has had several cases occurring within com- 
paratively short periods of one another. Such has certainly been 
the writer's experience. 

Tetanus may be traumatic or be idiopathic, according to the 
current authorities of the present day. In view, however, of the 
latest investigations, there may be reasonable doubt of the exist- 
ence of the latter variety. As in erysipelas, it is not difficult to 
assume the presence of some small wound in which the organisms 
may have effected a lodgment. Cases of tetanus arising from so 
trifling an injury as a hang-nail have been reported, and the disease 
may become a complication of an internal injury, as a simple frac- 
ture. It is not improbable, therefore, that in the form of dust the 
organisms may be inhaled or be swallowed, and that subsequently 
an intravascular infection of the injured tissues may occur. A 
more important distinction is that made between acute and chronic 
tetanus. Puerperal tetanus and trismus nascentium are varieties 
usually considered as a group by themselves, but they are in reality 
not distinguished etiologically from traumatic tetanus. 

Acute tetanus usually appears during the first week of the period 
of the healing of a wound. Yandell found that of 415 cases the 
disease supervened in two weeks in 196 cases. In the remainder — 
that is, those in which the disease appeared after the fourteenth 
day — the recoveries exceeded the deaths. As chronic tetanus is 
much more liable to terminate in recovery than the acute form, it is 
probable that in most of those cases in which the symptom appeared 



43 8 SURGICAL PATHOLOGY AND THERAPEUTICS. 

late the disease ran a chronic course. Of 367 cases reported in the 
Surgical History of the War, 287 occurred during the first two 
weeks after the injury or the amputation. 

Sometimes, then, during the first or the second week of the con- 
valescence from an injury, without any warning as shown by the 
state of the wound or the general condition of the patient, the first 
stage of the disease makes its appearance. After a comfortable 
night's rest, probably the last the patient will have, he awakes 
with a sensation of having taken cold. He complains of a stiff 
neck, but thinks little of it. Such a complaint on the part of the 
patient should put the surgeon on his guard, for, although it may 
be a symptom of a slight ailment only, it is almost the invariable 
precursor of the other symptoms of tetanus. During the day there 
is in the muscles of the jaw a slight stiffness, which renders it dif- 
ficult for the patient to open his mouth. This stiffness is not pain- 
ful, and it may still be regarded by the patient as a trivial matter; 
but this stage of comparative comfort does not last long, as the 
disease progresses apace. There is soon pain in the muscular con- 
tractions, which now become so powerful and continuous that the 
jaw cannot be opened and considerable difficulty is experienced in 
swallowing even liquids. In the mean time the "stiff neck" has 
included all the muscles that hold the head and the neck to the 
body. On examination of the jaws the masseters are distinctly 
felt in a state of rigid contraction, as hard as iron and with well- 
marked borders. Attempts to approach the chin to the sternum 
directs attention to the rigidity of the muscles at the back of the 
neck. If the hand is now passed down to the abdomen, the 
parietes are felt as firm and rigid as a metal plate; before the day 
closes the muscles of the back may already be affected, and the 
patient is unable to lie upon his back owing to the arching of the 
spine, or the opisthotonos, thus produced. There is already reten- 
tion of urine, which, when drawn with the catheter, appears to be 
abundant and of a normal color. The distress of the patient has 
now become great, owing to the painful nature of the muscular 
spasm, which is not only extensive, but is also continuous ; that is, 
u tonic." Attempts to swallow cause pain and distress, owing to 
paroxysmal increase in the muscular contraction. After a sleepless 
night the patient the next morning is found well advanced into the 
stage of full development of the disease. The locking of the jaws 
is as complete as before, and nearly all the voluntary muscles of 
the body except those of the upper extremities are involved. The 
arms may also be involved, but only to a partial extent. The lower 



TETANUS. 439 

extremities are rigidly extended. The patient is now extremely 
sensitive to disturbance of any kind: attempts to move him in bed, 
to administer nourishment, or to pass the catheter bring on a par- 
oxysm of convulsive action of a most painful character. Even the 
muscles of the face are affected ; the eyelids are seamed, the nostrils 
are raised, and the mouth is puckered in a peculiar way, while its 
corners are drawn back by the contraction of the cheeks. The eyes 
are drawn in and partly closed, and occasionally there is strabis- 
mus. The expression, which is peculiar to itself, can be likened 
neither to that of pain nor that of mirth. The so-called "sardonic 
grin" (risus sardonicus) is perhaps the best term that can be 
applied to it. Once seen by the surgeon, it is never to be for- 
gotten. The writer remembers having seen the typical risus in 
one only of the cases that have been under his care. Poncet 
remarks that the surgeon in charge would never be able to 
recognize his patient after recovery. Poland mentions a case 
where the disfigurement remained after convalescence, and was 
still quite marked after a period of eleven years. 

While all the muscles mentioned are still in a state of tonic 
spasm, there will be waves of convulsive spasm throughout the 
body, produced by any disturbing influence: these spasms now 
become more frequent and violent. The muscular contraction at 
this time is extremely painful, and any attempt to prevent it or to 
straighten the limb may lead to rupture of the muscular fibre. 
Larrey reports rupture of the rectus abdominis muscles owing to 
violent spasms brought on by putting the patient into a cold bath. 
The same accident is mentioned by Curling, and Dupuytren has 
observed rupture of the muscles at the back of the neck. Des- 
portes records double fracture of the neck of the femur from mus- 
cular action, and Poncet mentions a case of rupture of a fatty heart 
in an alcoholic subject. 

The reader must not gain the impression that the patient tosses 
wildly about in bed: on the contrary, he keeps as still as possible, 
and such a patient might easily be passed in the ward without 
appreciating the fact that he was the victim of so terrible a disease. 
On closer inspection, however, he will be found lying upon his side, 
with his head drawn rigidly backward and with a deep hollow in 
the curve of the spine, which curvature becomes greatly exaggera- 
ted on turning down the bed-clothes. His mind is perfectly clear, 
but the rigidity of the muscular contractions of the mouth and in the 
chest does not enable him to emit more than muffled groans. The 
spasm of the sphincters renders movements of the bowels or of the 



440 SURGICAL PATHOLOGY AXD THERAPEUTICS. 

bladder very difficult. There is at this time but little fever; the 
temperature-curve is iu no way characteristic iu this disease, but 
as death approaches, and even post-mortem, the rise may be exces- 
sive. There will be found, however, after each convulsion a tend- 
ency to perspiration, which may become quite a characteristic 
feature of the case. With each active and extensive innervation 
of muscular fibres there is without doubt an increased heat-produc- 
tion, and the diaphoresis is therefore a means by which a corre- 
sponding heat-elimination may be maintained. The post-mortem 
hyperpyrexia which is occasionally seen, the thermometer running 
to ioc/, ii2 c , and 113° F., may be in part due to the cessation of 
active heat-elimination, but it is probably due also to the action of 
the ptomaine on the thermic centres. 

During the height of the disease — that is, on the third or the 
fourth day — exhaustion becomes marked from loss of nourishment 
and of sleep. Short periods of sleep may be obtained by drugs, 
during which there is some relaxation of the muscular spasm; but 
no complete remission ever occurs, and the patient is soon startled 
out of a disturbed slumber by renewed convulsive movements. 
Attempts to give food may bring on spasm of the glottis, death 
having occurred during such a crisis. Attempts to expectorate the 
accumulated mucus may also produce the spasm. The convulsion 
usually lasts a few seconds only, during which there is also cya- 
nosis of the face and its muscles are contracted; the pupils are nor- 
mal; there is some foaming at the mouth; and the lips have a 
deeper hue. Dyspnoea is increased, and the patient makes forcible 
attempts to get his breath; the abdomen is pushed forward, and the 
patient may rest upon his occiput and heels in the position of 
opisthotonos. The pulse is greatly accelerated, and it may reach 
to 160 (Poncet). Death from heart failure may also occur during 
this period of prostration. In the last stages of the disease the 
mind continues clear, delirium is extremely rare, and the patient is 
fully sensible of the agonizing spasms to which the slightest noise 
or disturbance in the room gives rise. The face is pale and ema- 
ciated, and if not convulsed there is an expression of great appre- 
hension. The voice is feeble and the skin is constantly bathed in 
sweat. It is in this period that the temperature may rise, and in some 
cases may reach a very high point. During the last moments the 
tetanic spasms may relax, but they are usually maintained until 
the end. 

In tropical climates the period of acute tetanus may greatly be 



TETANUS. 441 

shortened, and cases are reported in which death has supervened a 
few hours after the onset of the attack. 

Contraction of the muscles of one side of the trunk may occur 
occasionally, but pleurosthotonos is rare. When the symptoms are 
continued beyond the fifth day, there is hope that the disease may 
assume the form known as chronic tetanus. The cases of recovery 
from acute tetanus that occasionally occur usually go through a 
chronic stage before convalescence takes place. 

In chronic tetanus the first symptoms usually appear at a later 
date after the injury or operation than in acute tetanus. There is 
hope, therefore, if no symptoms are seen until the third week, 
that there may be this type to deal with. The order in which 
symptoms appear is the same as that in the acute form. The stiff 
neck, the locked jaws, and the rigidity of the muscles of the trunk 
are all present, and they may be of great severity; but, although 
the development of the disease may be rapid, there are periods 
during which the patient experiences relief from muscular contrac- 
tions. An entire day may pass without relapse. The periods of 
quiescence between convulsions may, at all events, be more pro- 
longed than those in the acute type; nourishment can be given, 
and the strength of the patient may correspondingly be main- 
tained. As time passes che interval between the convulsive seiz- 
ures becomes more prolonged and the convulsions are less severe; 
deglutition becomes less painful. The prostration, however, is 
extreme, and any unusual excitement or irritation, such as the pas- 
sage of the bougie, will bring back the spasms. Sleep, however, 
becomes more prolonged and more refreshing. Convalescence 
finally sets in, though it is liable to be accompanied with several 
relapses. The disease may be thus extended over a considerable 
length of time. Cases of six weeks' and of two months' duration are 
occasionally seen; Yandell reports one case in which the duration 
of symptoms was two hundred and forty days. 

Head Tetanus, or Tetanus Hydrophobicus, an affection first 
described by Rose, occurs after injuries in the region of distribution 
of any of the twelve cranial nerves; consequently it is chiefly con- 
fined to the head. It is characterized by spasm of the pharyngeal 
muscles and paralysis of the facial nerve, as well as trismus, and 
occasionally tetanic contractions of the muscles of the neck and 
abdomen. Rose explains the paralysis of the facial nerve by com- 
pression in the petrous portion of the temporal bone, due to swell- 
ing of the nerve. According to Brunner, the reported symptom 
of facial paralysis is due to an error of observation. Brunner 



442 SURGICAL PATHOLOGY AND THERAPEUTICS. 

injected pure cultures of the tetanus bacillus at different points on 
the heads of rabbits and guinea-pigs, and succeeded in producing 
head tetanus. Paralysis of the affected side of the face was, how- 
ever, absent. The asymmetry of the two halves of the face was 
caused by tetanic contractions. If the injection was made in the 
median line, both sides of the face were affected; if one side was 
inoculated and the facial nerve of the same side divided at the 
same time, the contractions of the muscles were prevented. 
Klemm by a careful analysis of twenty cases disproves Brunner's 
theory, it being evident that paralysis of the facial nerve occurs 
in the majority of cases with its characteristic symptoms. The 
sequence of symptoms in this form of tetanus resembles that 
described by Rosenbach in tetanus produced experimentally in 
animals, in whom the muscular cramp begins at the point of inoc- 
ulation and spreads to other muscles. The paralysis is due to infec- 
tion, probably by a toxine, in the same way that paralysis occurs 
in diphtheria and other infectious diseases. Albert, in fact, places 
this affection in the class of the paralysies infectieuses. 

Cephalic tetanus occurs usually after a wound in the face. Rose 
reports the case of a coachman who received a blow from a whip- 
handle below the left orbit. In another case a blow was received 
in the temple during a street-brawl, and the patient was left uncon- 
scious in the gutter for several hours. In a case reported by Bern- 
hardt the disease followed the removal of a wen from the neighbor- 
hood of the left orbit. The paralysis of the facial nerve almost 
always occurs on the same side as that on which the injury is 
received. There is usually marked paralysis of the lower lid, the 
eye of the affected side remaining open after an attempt is made 
to close the lids. There is generally trismus, and occasionally 
spasm of the abdominal muscles is also mentioned. A marked 
feature of this form of tetanus is difficulty in swallowing, which 
symptom has given rise to the term tetanus hydrophobicus. 
This symptom, however, is not always present. 

Head tetanus is not always fatal. As in the ordinary form of 
tetanus, many of the chronic cases recover. Gueterbock and Bern- 
hardt collected seventeen cases with four recoveries. Klemm found 
that recoveries occurred almost invariably in the chronic cases, 
which lasted from four to twelve weeks. In a collection of twenty- 
four cases of head tetanus seven recovered, and of these six were 
cases of chronic tetanus. 

As to the character of the wound in a case of tetanus, there is 
little to show that the bacilli produce any marked local effect 



TETANUS. 443 

during their growth. Poncet speaks, however, of a peculiar con- 
dition of the wound at the outbreak of the disease. The suppura- 
tive process is less healthy in character and the tissues appear to be 
irritated. Occasionally there is a slight blush around the edges of 
the wound, and sometimes evidences of lymphangitis are seen near 
a wound of the extremity. There may also be a slight pricking 
sensation in the affected member, which may even be painful. 

Wounds of the extremities are said to be followed more fre- 
quently by tetanus than those in other regions. This statement 
is in accord with Yandell's figures. He says: "The popular 
belief that injuries of the foot are more liable than those of other 
parts to be followed by tetanus is quite confirmed as to punctured 
wounds in this situation, the large majority being inflicted by nails 
run into the foot. ' ' Of the 505 cases reported in the Surgical His- 
tory of the War, all but 76 were wounds of the extremities. It is 
probable, however, that the nature of the injury is a more important 
etiological factor than is its situation, and that tetanus more fre- 
quently follows wounds of the extremities is due to the fact that 
punctured wounds are more frequent in those regions. The pres- 
ence of the bacillus tetani on dirty hands and feet may also form an 
important factor. Occasionally the disease will be found to follow 
the infliction of a certain kind of injury. The " deadly toy pistol," 
so well known to Fourth-of-July celebrations, has been responsible 
for many cases. Here it would seem that there is a combination 
of predisposing causes — youth, anatomical situation, a lacerated or 
a penetrating wound, dirt from the street, and finally fragments 
of gravel from the detonating composition. The presence of for- 
eign bodies in wounds has always been supposed to be a frequent 
cause of tetanus. The wound, however, may be extremely slight, 
as a contused wound of the toe with or without fracture, a trivial 
affair; but if the bacillus has found a suitable lodging and is well 
protected from oxygen, the development of the organism will be 
possible. The penetrating nature of gunshot wounds, such as are 
inflicted in battle, combined with certain predisposing causes, ex- 
plains the relative frequency of tetanus in military surgery. That 
there should be a certain amount of inflammatory reaction in the 
wound is to be expected when infection has taken place; but the 
moderate number of organisms found probably accounts for the 
fact that more marked symptoms of inflammation are not present. 
The existence of such symptoms of a septic inflammation as Poncet 
describes can probably be accounted for by a mixed infection. 

The testimony as to the post-mortem changes in tetanus is quite 



444 SURGICAL PATHOLOGY AND THERAPEUTICS. 

conflicting. As a rule, evidence of inflammation of the brain and 
its meninges is wanting, but a number of observations point to 
inflammation in the upper portions of the cord. The great diffi- 
culty in preparing so delicate structures for microscopical study- 
throws doubt on many of the reports, but enough remains to prove 
that inflammation of nerve- tissue,. both central and peripheral, is 
generally present. Doubtless a fresh study of the field in the light 
of the present bacteriological knowledge will bring out many inter- 
esting morbid changes hitherto unobserved. 

Larrey, after the battle of Waterloo, performed a great number 
of autopsies in cases of tetanus, and found evident traces of inflam- 
mation of the cord and the membranes. Grinelle (1857), in a sum- 
mary of 52 cases of tetanus, reports that 29 presented lesions of the 
cord and the membranes. In 3 changes were noticed in the brain, 
and in n in the nerves and muscles. Lockhart Clarke, the best 
authority of the time, found in six cases lesions of the cord of 
different kinds and of surprising extent. He says: (< It seems to 
consist precisely of disintegration and softening of a portion of the 
gray substance of the cord, which appeared in certain parts to be 
in a state of solution." 

Ranvier, however, examined four cases from four to twelve 
hours after death, and prepared the cords for microscopical exam- 
ination with the greatest care, but failed to find anything abnor- 
mal. Verneuil believes that the lesions are dependent entirely 
upon reflex action, and Brown-Sequard expresses the theory that 
the morbid changes are due to an ascending neuritis ; and indeed 
in many cases there is a redness of the neurilemma of the nerves 
corresponding to the locality of the wound. Both Michaud and 
Aufrecht found lesions in the lumbar portions of the cord. Laveran 
examined the nerves of a patient who died of tetanus following 
amputation of the leg. He found proliferation of connective tissue 
in the tibial nerve, but no changes in the cord. 

In America, Amidon claims to have found extensive changes 
in the nervous system; small thrombi and exudation in the dura 
mater; degenerative changes in the brain; evidences of inflamma- 
tory changes at the points of origin of the cerebro-spinal nerves ; 
and lesions in the cord. Jewell thinks there is little doubt that 
there is usually irritative disease in certain not very well defined 
tracts of the gray matter of the spinal cord and the medulla oblon- 
gata, more especially of the latter. ' ' From these central diseased 
parts excitations are propagated along the motor tract, down the 
medulla and cord, and thence along the motor nerves to the 



TETANUS. 445 

affected muscles." In the spinal cord the chief seat of the dis- 
order, he thinks, appears to be in the posterior cornua and the 
contiguous central gray matter, the disease at times invading the 
related white columns. Such changes are more frequent in the 
cervical portion, but the appearances observed depend greatly 
upon the duration of the case. Neither the motor nor the sen- 
sory tracts are invaded alone, but the precise point of irritation 
appears to be in an intermediate region through which transfers 
in reflex action are made, and there is consequently great exaltation 
in the reflex irritability in this disease. 

This brief review of the question is enough to satisfy one that 
the virus acts with more or less power chiefly upon the nervous 
centres of the cord and the medulla, but the data do not yet seem 
to be sufficient to establish the fact of multiple neuritis or irritation 
of the trunks or branches of the nerves over and above that of other 
tissues to which the virus may be conveyed. 

The diagnosis of tetanus is usually not difficult in the fully- 
developed stage of the disease, but it is in the earliest stages that 
the surgeon should be warned of what is about to come. Stiffness 
of the jaws may be due to inflammatory affections of the mouth or 
the teeth or to abscess of the cervical glands. When the external 
signs of inflammation are wanting, the latter source of disturbance 
might be overlooked. 

Rheumatic inflammation of the temporo-maxillary articulation 
may also prevent the patient from opening his mouth, but the signs 
of local inflammation are not difficult to discover if carefully sought. 
Hysterical contraction of the masseter muscles is not likely to give 
rise to a mistake in the diagnosis, for the surgeon's attention is not 
usually called to such a condition until time has long since solved 
the question. Colles of Dublin undertook to describe the different 
forms of reflex contractions which may be mistaken for tetanus. 
Temporary spasms following the dressing of a painful wound men- 
tioned by him would not probably lead to a mistake in diagnosis. 
Tetanic spasms due to peripheral irritation of the nervous sys- 
tem, such as by a scar or a foreign body, are at times severe, and, 
according to some authors, may be fatal. Some of these cases are 
probably true infective tetanus ; others may be examples of severe 
reflex irritation, and Larrey's case of sudden cure following the 
division of a scar may have been one of this type. 

The question of death by tetanus or by strychnia-poisoning has 
been raised in medico-legal cases. In the latter condition, however, 
there is usually no lock-jaw, and if the masseters are affected at all, 



446 SURGICAL PATHOLOGY AND THERAPEUTICS. 

it is toward the end of the scene. In strychnia-poisoning there is 
hyperesthesia of the retina and objects seen are colored green. 
During a paroxysm the mouth foams, the jaws are joined together, 
and the teeth lacerate the tongue. There is also spasm of the mus- 
cles of the limbs and body, with arching of the back, which symp- 
toms with laryngismus are first in order to appear. When the dose 
is small and is repeated, there will be a corresponding intermission 
and a return of all the symptoms. In tetanus the disease begins 
with mild symptoms, and it is progressive and continuous. In 
acute poisoning the symptoms may last only for a few minutes. 
In temperate climates the most acute forms of tetanus last from 
two to three days. 

Tetany, which it might be supposed would resemble tetanus, is 
a disease not often seen in America: it affects chiefly young persons, 
and consists in tonic spasms of various groups of muscles, most 
frequently those of the upper extremities. The attack is preceded 
by vague tingling pains, followed by a sense of stiffness in the 
affected group. The position of the hand during the spasm is 
peculiar, resembling the posture of the accoucher's hand when 
about to make a vaginal examination. Opisthotonos may occur, 
but there is never trismus. The attacks are short and are more or 
less localized, and Trousseau's symptom, seen in no other convul- 
sive disease, is always present. This symptom consists in the 
peculiarity that pressure upon the nerve-trunk leading to the 
affected group of muscles always brings on a characteristic 
attack. 

The febrile nature of meningitis and the frequency with which 
it is accompanied by pain in the back of the head, as well as by 
the absence of the great reflex excitability, serve to distinguish 
that affection from tetanus. 

Hydrophobia is supposed by some authors to resemble tetanus, 
owing to the difficulty of swallowing which occasionally arises in 
the latter disease. Any one who has once seen both diseases would 
find no difficulty in distinguishing them. The portraits of the two 
diseases are indeed strikingly different. The countenance and 
bearing of the hydrophobic patient are those of excitement and 
mental distress. In the early stages of hydrophobia the patient 
does not take to his bed, and the so-called "spasm" appears 
only on attempting to swallow, and it is limited to the muscles 
of deglutition and respiration. The facial paralysis is a sufficient 
guide to diagnosis in tetanus hydrophobics, where there is diffi- 
culty in deglutition. External muscular spasm is the characteristic 



TETANUS. 447 

feature of tetanus. There is no mental excitement; although the 
muscles of the face are distorted, the expression of the eye is natural. 
It is the endeavor of the tetanic patient to keep as still as possible, 
whereas the hydrophobic patient is constantly moving about. In 
the later stages mania is present in hydrophobia, but in tetanus 
the mind is clear to the last. 

The prognosis of tetanus depends almost entirely upon the 
acuteness of the symptoms. Acute tetanus is one of the most 
fatal of diseases. In chronic tetanus the percentage of mortality 
is very much lower. According to Hippocrates, the patient dies 
on the third, the fifth, the seventh, or the fourteenth day. If he 
survive this period he recovers. According to the tables of the 
Surgical History of the War, of 337 deaths, 287 occurred during 
the first week of the disease. On the eighth day there were but 7 
deaths. In Yand ell's 415 cases there is a marked falling off in 
deaths on the fifth day, when there were but 11 deaths, from which 
time the percentage steadily diminished. 

Traumatic tetanus appears to be more fatal than idiopathic 
tetanus. Those cases occurring after injury received upon the 
field of battle appear to be the most fatal of all. In the Civil 
War 505 cases are recorded, of which 451, or 89.3 per cent., 
died. 

Poncet found a mortality of 90.6 in 713 cases; of Yandell's 
cases, which were collected from various sources, 213 recovered 
and 182 died. 

The date of invasion of the disease is an important element in 
the prognosis. In Yandell's cases the disease supervened in two 
weeks after the injury in 196 cases: of these, 62.5 per cent. died. 
11 But when tetanic symptoms are delayed until the fourteenth day 
recoveries are notably in excess of deaths — 23 per cent." Tetanus 
is seen more frequently in the male sex, and it is a disease of early 
life: cases are rarely seen in patients over fifty years of age. The 
gravity of the wound does not appear to have any influence upon 
the severity of the disease. It must not be forgotten that the 
figures mentioned above do not take into consideration tetanus 
of the tropics. There the disease is not only much more fatal, 
but is also much more frequent. According to Poncet, the num- 
ber of deaths from tetanus in England amounts to 0.0031 of the 
total mortality, but in Bombay the figures rises to 3.9 per cent. 
The disease in that locality may prove fatal in a few hours after 
the most trivial injuries or even when produced by a sudden 
chill. 



44^ SURGICAL PATHOLOGY AND THERAPEUTICS. 

The treatmeitt of few diseases has been the object of such varied 
medication as tetanus. Not only is the number of remedies too 
great to attempt even an enumeration, but such a variety is also 
used in most cases as to render it difficult to judge of their respect- 
ive values. 

Yandell, after a careful study of this question, concludes that 
no one agent can justly be said to possess a decided superiority 
over any other. No attempt is made to draw any conclusions from 
the treatment employed in the cases which occurred during the 
Civil War. Yandell places chloroform at the head of the list in 
cases of acute tetanus, but also makes the significant statement that 
when tetanus continues fourteen days recovery is the rule and death 
the' exception, apparently independent of the treatment. 

Among the internal remedies which have enjoyed a more than 
usual reputation may be mentioned Calabar bean, chloral, cannabis 
indica, curare, nitrite of amyl, quinine, and opium. Calabar bean, 
or its active principle, when given in small doses, relieves the mus- 
cular contraction, the jaws relax, the head reposes quietly upon the 
pillow; if given in large doses, the spasm appears greatly aggra- 
vated. Poncet explains the favorable action of the drug by its 
effect upon the conductibility of the motor nerves, by which the 
muscular system is, as it were, isolated from the nerve-centres. 
He prefers to give it by the mouth rather than by subcutaneous 
injection, as the dose can more carefully be regulated and the 
action of the drug can better be observed by this method. From 
i to \\ grains of the extract may be given by the mouth every 
four hours, or from 15 to 20 drops of a 1 per cent, solution may be 
injected subcutaneously. The statistics of Knecht give a mortality 
of 45 per cent, in 60 cases in which this drug was used. 

Chloral seems to be most efficacious in chronic tetanus: it 
relieves pain and prevents spreading of the muscular spasm and 
recurrence of the convulsions. It appears to act by diminishing 
reflex excitability in the nerve-centres. It may be continued for 
one or two weeks at a time, and in this way an almost uninterrupted 
sleep may be maintained, which paves the way to convalescence. 
In large doses (from 100 to 200 grains a day) chloral will relieve 
muscular spasm in acute tetanus, but it does not appear to have 
any appreciable effect upon the mortality. According to Jewell, 
as much as n 20 grains have been given in twenty-four hours. 

Ore of Bordeaux cured one of his patients by the intravenous 
injection of chloral: 10 grammes of chloral dissolved in 20 grammes 
of water were injected into the right cephalic vein in the space of 



TETANUS. 449 

nine minutes; cyanosis disappeared at once, and all muscular con- 
traction ceased at the end of the operation; the patient fell into a 
quiet sleep. The relief was in another case only temporary, and 
in fifteen minutes the symptoms had returned. 

Chloroform may be administered by inhalation. Poncet relates 
a case where anaesthesia was produced six times, and at the last 
administration respiration suddenly ceased, but it was restored by 
artificial means, and the patient finally recovered under the con- 
tinuous treatment of opium. Simourin administered chloroform 
by keeping upon the breast of the patient a napkin upon which 
chloroform was dropped. The room was a small one, and the 
patient was thus exposed to the influence of the drug during 
twenty-two days. The patient recovered. Certain it is that the 
weight of evidence is in favor of the sedative action of this drug 
on the nervous system in cases of tetanus, as compared with that 
of other remedies of this class. Its action is said to be not so 
enduring as that of chloral. 

Opium does not appear to enjoy the popularity of chloral and 
chloroform. Large doses are required, and the digestive disturb- 
ance caused by the drug is a contraindication to its use. Adminis- 
tered hypodermically, it gives, however, great relief in some cases. 
The dose required is sometimes enormous, considering that the 
patient has but a short time to become habituated to the drug. 
The writer has known a young man to receive, before relief from 
pain was obtained, one hundred grains of morphine in the twenty- 
four hours. 

Bromide of potassium may be used in connection with chloral 
or, in the convalescent stage, as a substitute for that drug, but it 
is altogether too mild a remedy to produce any appreciable effect 
in the more active stages of the disease. The writer should hardly 
advise the surgeon to waste time in experimenting with any of the 
other drugs that have been used in the treatment of the disease. 
Those already mentioned are of use only by virtue of their sedative 
qualities, and they cannot be regarded as curative agents. They 
relieve the most overpowering of the symptoms, and in this way 
give the patient strength to live through the period during which 
the virus is in an active stage of development. 

So far as local treatment is concerned, it is important to 
remember that antiseptics, to be of any use, must reach the 
bacilli, which are already deeply imbedded in the recesses of a 
punctured wound. Those exposed to the air, being anaerobic, are 
not likely to develop. Punctured wounds, therefore, should 

29 



450 SURGICAL PATHOLOGY AND THERAPEUTICS. 

thoroughly be laid open and disinfected if there is any reason to 
suspect that infection has taken place. This infection is more 
likely to occur, as has already been shown, when dirt or dust is 
driven in with the penetrating foreign body. The large majority 
of punctured wounds recorded in Yandell's cases were inflicted 
by nails penetrating the foot. Any dressing applied should be so 
arranged that free drainage will be possible. A dry dressing, 
which might seal up a small opening, would in such case become 
a source of danger. Many a case of tetanus has doubtless been 
warded off in pre-antiseptic days by an old-fashioned poultice, 
which has favored suppuration and the discharge of the dangerous 
bacilli. In those cases to which attention has already been called, 
where nerve-irritation is a prominent feature, the reflex excitability 
has been greatly diminished by nerve-section. Some cases seem to 
have been cured by this operation, but in true tetanus the most 
that can be expected from this method is the removal of a power- 
fully disturbing influence on the nerve-centres. Permanent paral- 
ysis may of course result, but union may subsequently take place 
between the divided ends of the nerve. Nerve-stretching has also 
been tried, but the results have not been encouraging, although in 
isolated cases it has produced marked relief. Nerve-stretching is 
not to be thought of except in special cases when local indications 
seem to demand this operation. When a nerve is bound down by 
a cicatrix, it should be dissected out and thus be freed from a 
source of painful irritation. In certain cases when the wound is 
foul or is irritating, or when great laceration has exposed and 
mangled nerve-trunks, amputation may be necessary. 

The great sweating which is so characteristic of tetanus has 
suggested the use of warm baths and of other diaphoretics as a 
means of imitating Nature's method of relief. It is possible that 
some of the ptomaines may be eliminated in this way: it is unlikely 
that many of the bacilli would find their way into the sweat-glands, 
as bacteria are not usually so eliminated. The hot bath gives 
relief to the spasms while the patient is immersed, but removal 
from the bath brings the patient in contact with cooler media, 
which, together with the necessary disturbance, excite new con- 
vulsive movements. A. vapor bath may be administered to the 
patient while in bed. The vapor bath constitutes one of the clas- 
sical forms of treatment handed down from early times. The 
writer has seen it thoroughly tried without other result than to 
increase the patient's distress. 

In 1890, Behring and Kitasato published some experiments with 



TETANUS. 451 

reference to the origin in animals of immunity to diphtheria and 
tetanus. According to these investigators, the acquired immun- 
ity depended upon some property of the blood-sernm developed 
bv protective inoculations, and with this curative serum they 
were not only able to render animals insusceptible, but also to 
cure already infected animals. This immunity was brought about 
bv the injection of cultures of the tetanus bacillus, whose activity 
had partially been destroyed by the addition of trichloride of iodine. 
By diminishing the amount of the iodine the strength of the viru- 
lent culture could be increased. The serum of animals thus 
rendered immune could be used on other animals as a protective 
or curative agent. Tizzoni and Catani produced a protective result 
in animals by injecting very small doses of tetanus culture at first, 
and later by gradually increasing the amount of the culture. They 
were not able, however, to produce any therapeutic results on ani- 
mals with the serum of the animals so treated. The active princi- 
ple of the culture they called a "tetanus antitoxine," which may 
be obtained by precipitation by alcohol, and when used it is dis- 
solved in water or in glycerin. (See Appendix.) The curative 
effect of this blood-serum does not seem to have proved so pow- 
erful as was at first anticipated, and it is denied altogether by 
some observers. Other observers have succeeded, however, in 
curing animals when the treatment was begun soon after the 
onset of the symptoms of tetanus. 

Fourteen cases of the disease in man have been treated by the 
methods of Tizzoni and Catani; of these, ten were adults, who 
were all cured. There were four cases of tetanus neonatorum, 
three of which terminated fatally. This method consisted in in- 
jecting a watery solution of the antitoxine and in repeating the 
dose daily. No unfavorable symptoms followed the administra- 
tion of these doses in any of the cases. An analysis of the favor- 
able cases shows, however, that the majority of them were exam- 
ples of chronic tetanus. The cases reported by Roux and Vail- 
lard were also mild in type. It is therefore doubtful whether this 
new treatment is efficient in the acute type of the disease. 

Perhaps in no disease should the comfort of the patient so 
carefully be studied. Before active symptoms have set in the 
patient should be placed alone in a room so situated as to be 
quite free from disturbance of any kind, if that be possible. 
The light should be dim and the temperature should carefully 
be regulated. Officious nursing should be avoided. Nourish- 
ment is needed to sustain strength, and stimulants may be given 



452 SURGICAL PATHOLOGY AND THERAPEUTICS. 

in such combinations as to be least irritating to the throat. It 
may be necessary to use the catheter or to produce an action of the 
bowels. Skilled nursing should accomplish these tasks without 
undue excitement of the hypersesthetic nerves. With such minute 
care and attention to details as these rules imply treatment may, as 
Nicaise justly says, make chronic some cases of tetanus that began 
as acute. Every day added to the patient's life after the first week 
of the disease increases greatly his chances of recovery. Even the 
most acute cases sometimes get well, so that the surgeon should be 
encouraged to exert all the skill in his power or bring to bear all 
the resources of a great hospital, even in the most desperate cases, 
with some hope of saving life. 



XIX. HYDROPHOBIA. 

Hydrophobia is a disease of man caused by inoculation from a 
rabid animal due to a specific virus in the saliva. Hydrophobia, 
which principally affects the nervous system, is characterized by 
peculiar paroxvsms of suffocation, brought on chiefly by attempts 
at swallowing, by a catarrhal affection of the fauces, by a more or 
less pronounced febrile disturbance, and by an acute mania. The 
term rabies — or less frequently lyssa — is applied to the same disease 
in animals. 

Rabies is frequently observed in herbivorous animals, such as the 
ox, the horse, or the sheep. It is more commonly found in the car- 
nivora, such as the cat, the fox, the jackal, the wolf, and the dog. 
More rarelv it is observed in the skunk, in swine, in birds, and 
even in domestic poultry. Rabbits are susceptible to the virus, 
and they are used principally in experimental inoculations. The 
disease is always communicated by inoculation from animal to 
animal or from animal to man, and does not arise de novo. 

Infection does not always follow the bite of a rabid animal: the 
large majority of persons bitten are supposed to escape, but in most 
cases this immunity is due to protection by the clothing or the fail- 
ure to penetrate the epidermis, or, more probably still, to the fact 
that the supposed rabid animal did not suffer from rabies. Bites 
on exposed portions of the body by animals undoubtedly mad are 
probably followed by hydrophobia in the large majority of cases. 
The disease is not always caused by a bite, for a previously existing 
wound or an abrasion may be inoculated by the saliva conveved by 
the tongue of the animal while licking the skin of its master. 

In the dog the disease presents two types, the dumb and the 
furious rabies. In the furious form a change is first noted in the 
habits of the animal. He becomes uneasy and depressed, and is 
dull, wandering aimlessly about and hiding in obscure corners. In 
this early stage his saliva is already poisonous, and, as he occasion- 
ally exhibits a tendencv to be affectionate to some other animal of 
the household or to his master, his caresses are dangerous. Fre- 
quently, however, if disturbed, he growls and shows no inclination 
to move, but will still obey the voice of his master. He is subject 
to hallucinations, and will snap and snarl at imaginary objects. 

453 



454 SURGICAL PATHOLOGY AND THERAPEUTICS. 

Doleris mentions the case of a bull- terrier which was observed to 
peck, like a hen, at the hay scattered about the floor of the stable 
when there were no other symptoms. He was isolated and died of 
rabies. The symptom of hydrophobia does not exist in the dog: on 
the contrary, the dry and swollen state of the mucous membrane of 
the fauces causes him to seek water to slake his thirst. The animal 
will plunge eagerly into the water and bury his head beneath it to 
relieve this symptom. Rabid animals have been known to swim a 
stream to attack animals on the opposite bank. 

At first the dog takes his nourishment as usual, but he soon 
becomes voracious in his appetite, and in intense forms of the dis- 
ease he often exhibits a depraved taste, avoiding ordinary food, but 
tearing all kinds of objects and swallowing the fragments. He may 
even swallow his own excrement. The quantity of the saliva is not 
great at first, but it is more abundant in the earlier stages than 
later. It then becomes tenacious, adhering to the gums, and 
appears almost as white as snow. The dog's bark is quite cha- 
racteristic: it is at first husky, and in some cases ends in a plaintive 
howl somewhat like that of a dog barking at the moon. The sight 
of another dog generally brings on a paroxysm of rage — a symptom 
sufficiently marked and constant to be of value in cases of doubtful 
diagnosis. The affected brute will pass by other animals and man 
to attack another dog. He is usually quite insensible to pain: a 
red-hot poker may be grasped and held in the mouth. He can be 
beaten without exhibiting signs of pain, and often commits self- 
inflicted wounds. There may be great sensitiveness of the scar of 
his cicatrized wound. 

As the disease progresses there is marked inability to swallow 
either fluids or solids, and loss of strength is often progressive and 
rapid. The respiration is hurried. During the later periods of 
the disease delirium becomes a marked symptom. The animal is 
now seized with a desire to escape from the house, and it is during 
this stage that he becomes dangerous. His pupils are dilated, and 
his expression is terrible in its fierceness. He now attacks all ani- 
mals within reach, and also man. While biting and tearing he is, 
according to Suzor, always silent; unlike the non-rabid dog, which 
fights and barks at the same time. This stage is followed by one 
of great prostration. His gait is now tottering and his senses are 
dulled. After wandering about for a few hours, or it may be days, 
paralysis of the hind-quarters supervenes, and he dies of exhaus- 
tion and asphyxia. The disease usually lasts from six to eight 
days, but it may be prolonged for several days. 



HYDROPHOBIA. 455 

The period of incubation of rabies varies from three to four weeks. 
It is occasionally very much longer. In nearly every case the disease 
terminates fatally. 

Dumb rabies is commoner than the furious form. The initial 
svmptoms closely resemble those of furious rabies. The voice in 
dumb rabies is much altered from the first, and in the later stages 
it is lost. The expression is sad and startled: the mouth is open, 
owing to the paralysis of the lower jaw, and the tongue hangs out 
drv and discolored and covered with dirt. Persons not acquainted 
with these symptoms might suppose the animal to be suffering 
from a bone lodged in the throat, and would, in making efforts to 
remove it, certainly expose themselves to inoculation. Paralysis 
of the hinder extremities supervenes, and it is soon followed by 
death. The symptoms in rabies appear to vary according to the 
regions of the cord which may be chiefly affected. 

On post-mortem examination the mucous membrane of the 
mouth and the tongue is found to be of a livid color. Ulcera- 
tions of the mucous membrane, supposed to be due to vesicles 
characteristic of the disease, are frequently caused by the swal- 
lowing of foreign bodies of various kinds, such as stones, straw > 
hair, and glass, with which the stomach is found to be filled. 
There is great congestion of the tracheal and bronchial mucous 
membranes, and there is a marked contraction of the bladder. 
Congestion of the central nervous system is also found. 

The etiology of hydrophobia in man is not yet fully explained. 
Pasteur has been unable to demonstrate any form of bacteria which 
can be identified with the disease. Fol and Rivolta have lately 
described a coccus in this disease, but their observations have not 
been confirmed by others. The virus is probably never absorbed 
through the mucous membrane: Doleris mentions cases of persons 
who had eaten with impunity the flesh of rabid animals. The bites 
of certain species are said to be more dangerous than those of other 
animals. In Russia it is believed that wolves are more dangerous 
than any other animals, and in America the bite of the skunk is 
greatly dreaded. There is probably no difference in the strength 
of the virus in these animals, the more frequent poisoning being 
probably due to their sharp teeth and to the greater certainty of 
inoculation through the penetrated skin. 

The period of the year is supposed to exert a favorable influence 
upon the development of an epidemic of hydrophobia. The results 
of the work of Pasteur's Institute show that the disease is not con- 
fined to any one period of the year, and that, contrary to the com- 



45 6 SURGICAL PATHOLOGY AND THERAPEUTICS. 

mon belief, it is not a disease of the summer months. Two at least 
out of four cases which have come under the writer's observation 
occurred during the summer. Pasca of Milan found the disease 
occurred more frequently during the spring and autumn months. 

The period of incubation of the disease in man is quite variable, 
although the first symptoms usually make their appearance in the 
second month after exposure. According to Brouardel, the disease 
rarely occurs after the third month, and quite exceptionally after 
the sixth month. The symptoms manifest themselves earlier when 
the bites are numerous and severe, and they appear also earlier in 
children than in old people. Cases are quoted where the disease is 
said to have supervened several years after infection, but the exten- 
sion of the period of incubation beyond those above named is to be 
received with caution. 

The disease appears to be very much commoner in France than 
in America. Further reference will be made later to the number 
of cases occurring in France. In the city of New York there were, 
during a period of thirty -five years, only 76 deaths from hydro- 
phobia. In 9 of these years there were no deaths, and it has twice 
happened that for two years in succession there was not a death. 
In Boston and its vicinity H. C. Ernst reports an epidemic of 
rabies among dogs during 1889 and 1890, some 60 cases being 
observed at the Harvard Veterinary Hospital. During the summer 
of 1890, 3 cases in man were observed at the Boston City Hospital, 
from 2 of which material was taken by Ernst and successfully 
inoculated into rabbits, which died with the usual symptoms. 

The disease may appear either as a delirious or as a paralytic 
form, precisely as in the dog, but the delirious form is the variety 
by far the most frequently observed. 

The first stage of the disease is characterized by melancholia. 
It is marked by insomnia, by loss of appetite, and by great depres- 
sion of spirits, and occasionally there are shooting pains found 
radiating from the seat of the wound or in the affected limb. In a 
case reported by Shattuck the patient first complained of severe 
pain in the back of the head and in the neck; on the next day he 
went as usual to his business, but he returned home at an early 
hour much depressed, saying, u I have come home to die." Dif- 
ficulty of swallowing appeared on the same day. This stage does 
not last more than twenty-four or forty-eight hours, although some 
authors have described cases in which headache, insomnia, and 
anorexia were observed for three weeks previous to the outbreak of 
hydrophobia. 



HYDROPHOBIA. 457 

The cases seen by the writer had all reached the stage when that 
most striking- symptom of the disease — difficulty in swallowing — 
was plainly marked. The appearance of the patient at this time, 
although not presenting symptoms likely to attract the attention 
of the casual observer, is most characteristic. The picture thus 
presented is one not likely to be forgotten or to be mistaken for any 
other disease. On entering the apartment one looks around invol- 
untarily to find the patient, for the individual, quietly seated with 
his back partly turned to one, is dressed in his ordinary clothing 
and gives no indication of suffering from any abnormal condition. 
A brief conversation, however, soon brings out the peculiarities of 
the case. His speech is perhaps the first function to betray the 
disease. The patient appears to be slightly out of breath, frequent 
short inspirations so altering his conversation as to give to it the 
so-called "sobbing " tone. It is, indeed, not unlike the speech of 
a child who has recently been crying and is endeavoring to control 
itself. The expression of the face at this time varies from one in 
no wise differing from a perfectly normal condition to a more or less 
wild or a haggard look about the eyes. Usually there is an appear- 
ance of depression or of anxiety, like that of a prisoner waiting for 
the verdict. But the most crucial diagnostic test is the glass of 
water. 

The following account of the attempts made by a patient to 
drink is given by Curtis, with whom the writer saw the case in 
consultation : 

" A glass of water was offered to the patient, which he refused to take, say- 
ing that he could not stand so much as that, but would take it up from a 
teaspoon. On taking the water in the spoon he evinced some discomfort and 
agitation, but continued to raise the spoon. As it came within a foot of his 
lips he began to gasp violently, his features worked, and his hand shook. He 
finally almost tossed the water into his mouth, losing the greater part of it, 
and staggered about the room, gasping and groaning. The respiration 
seemed at this moment wholly costal, and was performed with great effort, 
the elbows being jerked upward with ever} 7 inspiration. The paroxysm 
lasted about half a minute. The act of swallowing did not appear to distress 
him, for he could go through the motions of deglutition without any trouble. 
The approach of liquid to his mouth, however, would at once cause distress." 

It will be noticed that the "spasm," as it is called, does not 
involve the muscles of the pharynx and the oesophagus, but 
affects rather the mechanism of the respiratory apparatus. It is 
true that many authors report spasms of the muscles of the 
pharynx, and even of the jaws and the extremities, but these are 
secondary to the overpowering sense of suffocation. The palpita- 



458 SURGICAL PATHOLOGY AND THERAPEUTICS. 

tions of the heart are also violent, and the cardiac disturbance has 
been described by Doleris as a spasme circulatoire. Of the nature 
of the hydrophobic paroxysm something further will presently be 
said. 

Distress is also caused by fanning the patient or by exposing him 
to a draught of air {aerophobia). In one case, on gently passing the 
fan to and fro behind the patient's head while other persons were 
conversing with him, the writer produced a disturbance sufficient 
to cause the patient to spring from his chair and to walk rapidly 
to the other side of the room. The patient did not appear, how- 
ever, to be conscious of what had disturbed him. In another case, 
a lump of ice being placed in the patient's hand, he flung it from 
him with expression of great pain; on being asked what his sensa- 
tions were, he explained that it felt like a red-hot coal. 

Already at the end of the first day the mental condition of the 
patient is evidently impaired, the expression of the eye has grown 
more wild, and the speech has begun to be somewhat incoherent. 
Cephalalgia is a frequent symptom, and it is occasionally of great 
intensity. In one of the paroxysms of the case already referred to 
the patient would exclaim, " For God's sake, hold my head or it 
will burst !" 

There is at this time a secretion of viscid saliva, which can be 
seen accumulating about the teeth and the lips. The irritation 
of the fauces is great, and in the effort to expel from them the 
adherent secretions there is developed a loud and abrupt cough, 
which has probably given rise to the tradition that such patients 
"bark like a dog." 

Presently the paroxysms appear to come on spontaneously. The 
patient, who by this time has become fatigued by the nervous 
excitement, by the exhausting paroxysm, and by the inability to 
take food, has been persuaded to go to bed. The accumulation of 
saliva causes attempts to swallow or to expectorate, and the contact 
of the secretions with the fauces or with the lips causes irritation 
sufficient to bring on an attack. The paroxysms are doubtless 
caused also by mental apprehension of an impending attack. On 
the approach of the paroxysm the patient, who a moment before 
has been quietly lying in bed, may suddenly spring out of bed 
and grovel on his hands and knees in a distant corner of the room. 
Violent attempts at expectoration may occur. At this stage of the 
disease there will probably be more or less marked mental disturb- 
ance. The patient's opinion of the manner in which he has passed 
the night is quite unreliable. Acute mania may supervene, and in 



HYDROPHOBIA. 459 

one of the cases which the writer saw the patient escaped from his 
room early in the morning, and was found to have scaled a high 
fence and to have concealed himself at some distance from the hos- 
pital. Marked sexual excitement is frequently observed: in men 
the talk is obscene and painful emissions may occur; in women 
nymphomania may be present. During the period of mental ex- 
citement the patient may struggle fiercely with his attendants. 
Occasionally he may attempt to bite, but this is in no way cha- 
racteristic of his condition. In some cases during this stage mel- 
ancholia is present in a marked degree: the patients are the prey 
of nameless terrors, and many cases of suicide are recorded. 

After each paroxysm prostration becomes more marked, and in 
some cases coma may supervene temporarily. At the end of the 
second day, usually, the prostration is so great that the attacks are 
much feebler, and toward the close of the scene the patient may 
become comparatively quiet. The transition from prostration to 
coma is rapid, and the moribund stage is usually short. Febrile 
disturbance does not appear to be a marked feature, although occa- 
sionally it may appear with the outbreak of the disease; but pyrexia 
is present in the later stages, and in one case which the writer saw 
the temperature ran above 104 F. on the last day. The pulse 
usually is not greatly accelerated. 

There may also be a paralytic form of rabies in man, although 
this form is much rarer than is the furious form. Gamaleia of 
Odessa published an account of thirty cases. He found that the 
disease is the result of deep and multiple bites. At the onset there 
is considerable fever, malaise, headache, and vomiting. There is 
also pain in the extremities, particularly in the part bitten. Paresis 
and numbness appear in the group of muscles near the injured 
parts, these disturbances being followed by more or less complete 
paralysis. The paralysis then spreads, preceded or accompanied 
by sharp pain in the muscles invaded; the remaining limbs, the 
trunk, the rectum and the bladder, the face, the tongue, and the 
eyes, are all paralyzed, and finally there is paralysis of the respi- 
ratory centre, with more or less difficulty in swallowing liquids. 
Gamaleia says: "When well marked this respiratory lesion is the 
cause of dyspnceic convulsions in the muscles which are not yet 
paralyzed, then frequently return of breathing to the normal, but 
spread of the paralysis to the heart and death by syncope." This 
form of rabies has a duration of about one week. 

Dana says : "In questioning the many general practitioners 
from various parts of the country with whom I come in contact, I 



460 SURGICAL PATHOLOGY AND THERAPEUTICS. 

have found that many could recall cases of mysterious acute pro- 
gressive fatal paralyses whose nature and cause have completely 
puzzled them. It may be that the paralytic rabies in man is there- 
fore not such an extreme rarity." Gray believes that the symptoms 
of the so-called ' ' dumb rabies ' ' may be caused by simple purulent 
meningitis and meningo-encephalitis. 

Lyssa falsa seu nervosa, which is a term applied to a condition 
produced by the fear of rabies, is occasionally seen in hysterical 
subjects. It is not difficult to distinguish it from the true disease, 
as the period of incubation is too short, and a few days' or even 
hours' observation will decide the question, owing to the rapid 
development of the symptoms of true hydrophobia. Cases of lyssa 
falsa are said to have terminated fatally, but such a result may have 
been due to complications, such as an acute mania or some infec- 
tious disease. Birdsall saw a number of such cases, in none of 
which the patient died, but he would not say that death from 
fright of this kind was impossible. 

According to Curtis, "the hydrophobic paroxysm is to be likened 
to the shock of the shower-bath. The regulation of the respiratory 
centre is accomplished by an inhibitory influence. One of the 
most striking examples of this action is observed in the superior 
laryngeal nerve. Irritation of the divided central end of this nerve 
causes an immediate suspension of the respiration, the diaphragm, 
paralyzed and relaxed, being thrown into an attitude of extreme 
expiration." The same result may be produced, according to 
Brown-Sequard, by direct irritation of certain parts of the me- 
dulla. A similar influence is exerted by a variety of peripheral 
stimuli: powerful excitations of the nerves of general sensation, 
particularly the fifth pair, cause slowing of the respiratory move- 
ments. A similar effect is produced by psychical impressions pro- 
ceeding from the emotional regions of the brain and the medulla, 
as shown in the breathlessness experienced under circumstances of 
great alarm or excitement or grief. The superior laryngeal nerve 
supplies sensation to the mucous membrane of the base of the 
tongue, of the upper part of the anterior wall of the oesophagus, 
of the epiglottis, and the laryngeal mucous membrane. When 
stimulated by the irritating contact of foreign bodies, liquids, irri- 
tating vapors, and gases, paralysis of the diaphragm takes place 
with extreme respiratory relaxation, so that inspiration is for the 
time being rendered impossible. The same protective agency is 
brought into play in every normal act of swallowing, or even in 
inspiration itself, which is thus rendered, as it were, self-inhibiting. 



H YDROPHOBI. I. 46 1 

The breathlessness in the shower-bath or in cold sea-bathing is 
another example of the same inhibitory action. Similar sensations 
are produced by the attempt to swallow a glass of hot, steaming 
punch, which will sometimes "take one's breath away" by the 
same mechanism. Swimmer's cramp is probably also another 
example, resulting in sudden death from apncea, and is not due 
to " cramp" of the muscles, as is generally supposed. 

The hydrophobic paroxysm is not to be regarded as a convul- 
sion, unless, as Curtis graphically puts it, ik a drowning man unable 
to swim and thrashing about in the water, or a man clutched bv the 
throat and struggling frantically for life, can be said to have con- 
vulsions. " The paroxysms are rather to be regarded as sudden 
attacks of paralytic apncea due to temporary, partial, or complete 
inhibition of the respiratory centre taking place under the influence 
of peripheral impressions. The inhibitory stimulus may proceed 
from the area of distribution of the superior laryngeal nerve, being 
originated by attempts to drink and by accumulated saliva, or from 
the area of the fifth pair as a result of wetting the lips or the face 
or of fanning; or it may be due to an irritation of the nerves of 
sensation of the trunk and limbs or the nerves of special sense. 
The origin of the respiratory inhibition does not appear to Curtis 
to be due so much to an increase of inhibition as to diminished 
resistance of the respiratory centre, due to the structural changes 
which Gowers has shown are most intense in the respiratory centre 
of the medulla. All that is required, therefore, is a slight inhib- 
itory stimulus to reduce the activity of this centre to zero. Accord- 
ing to Putnam, it must either be assumed that the respiratory centre 
is abnormally susceptible to inhibitory influences or that the inhib- 
iting impulse is extremely powerful. As the structural lesions found 
in the medulla show an impairment of the nutrition of the respira- 
tory centre, the theory of over-sensitiveness to inhibitory influences 
must be rejected. There is no evidence that the impressions made 
on the skin or the mucous membrane are abnormally intensified: 
there is, however, the stimulus of emotional excitement which is 
always present in such cases. The paroxysm is therefore directly 
due, Putnam thinks, to the reaction on the respiratory centre of 
the morbid mental state of the patient. 

Gowers maintains that the phenomenon is not one of inhibition, 
but of irritability of the respiratory centres, particularly that por- 
tion which has to do with the process of extraordinary breathing; 
that is, the costo-superior respiration. According to this author, 
the nature of the symptoms and the lesions in hydrophobia seem to 



462 SURGICAL PATHOLOGY AND THERAPEUTICS. 

suggest that the poison has an action on the nervous centres in the 
following order: the medulla oblongata, the cerebral hemispheres, 
and the spinal cord. The effect on the medulla is the first, the 
most intense, and the most constant, especially in the early stages. 
The action on the spinal cord is rarely marked except in the latest 
stage. The action on the cerebral hemisphere is chiefly shown in 
the delirium which is so conspicuous in some cases in the later 
stages. 

Gowers carefully studied the microscopic condition of eight 
cases of hydrophobia in man and of one in a dog. The changes 
found in the spinal cord were comparatively slight. There was 
some hypersemia of the gray substance, but no cell-infiltration. 
The region in which the pathological conditions were most intense 
is what is known as the respiratory centre of the medulla, the region 
in which are situated the hypoglossal, pneumogastric, and glosso- 
pharyngeal nuclei. Then, in addition to the great distention of 
the minute vessels seen in the cord, there was found an aggrega- 
tion of cells in the perivascular lymph-sheaths. 

The cells were found sometimes in a single layer, and sometimes 
so densely packed as to compress the vessel they surrounded. In 
some instances they had extended beyond the perivascular sheath 
and had infiltrated the adjacent tissues. Here and there were 
patches of tissue infiltrated with leucocytes in this manner. In 
one case such an area was found between the hypoglossal and the 
pneumogastric nucleus. Gowers describes them as miliary abscesses. 
There was also a number of small round cells scattered through the 
adjacent tissue in greater numbers than in health. Many vessels, 
especially the veins, were distended with blood-clots (showing prob- 
ably the septic nature of the inflammatory stimulus). The nerve- 
cells presented comparatively little change: many of them had a 
granular appearance, which was more marked in some than in 
others that lay near them; others had a somewhat swollen appear- 
ance. The changes around the auditory, facial, and fifth nuclei 
were not so marked. The higher part of the pons was much less 
affected. Miliary abscesses had previously been observed by Kol- 
esnikoff. 

Fitz found the most extreme alteration in the part correspond- 
ing with the calamus scriptorius. The appearance most frequently 
met with was an infiltration of the adventitia of the veins with 
small round cells. Extravasation of blood was found in the peri- 
vascular spaces. The u miliary abscesses " were also seen, and in 
two instances actual abscesses were found (Fig. 75). So far as 



H YDROPHOBIA . 463 

other organs were concerned, Fitz found numerous slight hemor- 
rhages in the septum of the heart: no abnormal appearances were 
observed in the pharynx and in its submaxillary glands; the 



% ..• 










• .r . ^ 




• » • . 


















1% ,*.-. 










■'. 






• 




••■•■ 








. ■. * 








,: .fvi 




■■ ' 







m : & : ■■■:■ 



% 



■ ■ v. . S . 



Fig. 75. — Extravasation or "Miliary Abscess" in the Cervical Cord in a case of 

Hydrophobia. 

oesophagus from the bifurcation of the trachea downward was 
extensively cedematous. 

In one case examined by Wickham hegg the kidneys showed 
cloudy swelling, but, as a rule, no pathological changes of import- 
ance appear to have been discovered in the thoracic and abdominal 
viscera. Hyaloid masses have been found in the medulla by sev- 
eral observers, but as these are met with also in normal specimens, 
it is not certain whether in these cases they were of any patholog- 
ical significance. 

Although in the microscopical appearances above mentioned 
there is nothing that can be regarded as specific of the disease, 
still Gowers is of the opinion that "the distribution of the lesions, 
their intensity in the lower part of the medulla and in the neigh- 
borhood of certain nerve-nuclei are, as far as I am aware, pecu- 



464 SURGICAL PATHOLOGY AND THERAPEUTICS. 

liar to the disease and constitute a distinguishing anatomical 
character. ' ' 

Vesicles on the inferior surface of the tongue, once thought to 
be characteristic of the disease, are rarely found, and no special 
importance is now attached to them. The nerves of the part in 
which the bite is situated have been observed to present patho- 
logical changes: the myelin is found in a diffluent condition, the 
structure is softened, and the axis-cylinder is at times absent in 
many of the nerves. The same observation is recorded in the 
nerves arising from the medulla, such as the glosso-pharyngeal 
and the hypoglossal (Blodgett). Occasionally there is some hyper- 
semia about the region of the cicatrix, but in most cases no special 
change is observed. 

The writer has already intimated that treatment of the disease 
is futile. Powerful drugs of various kinds have been used, but no 
authentic cases of cure have ever been reported. It was claimed 
at one time that curare had cured a case, but, although Shattuck 
and Curtis report a most systematic course of treatment with this 
drug in two cases, no favorable effects were observed; and this has 
been the experience of others who have tried the drug. Until 
something in the nature of an antitoxine has been discovered, it 
is hardly worth while to discuss the therapeutics of the already- 
established disease. 

^^prophylactic treatment so wonderfully carried out by Pasteur 
merits, however, the most careful scrutiny. Pasteur's attention was 
first called to hydrophobia in 1880, having visited a case in one of 
the hospitals under the care of Lannelongue. 

In Pasteur's earlier experiments on animals he found that the 
virus existed not only in the saliva, but also in the brain, and that 
the period of incubation could be shortened greatly by inoculating 
the trephined brain of a healthy animal with the cerebral matter 
of a mad dog. Symptoms appeared in one or two weeks: by other 
routes the inoculation may not be followed by symptoms for one or 
two months. In fact, he soon found that the principal seat of the 
virus was in the central nervous system, where it may be obtained 
in great quantity and in a state of perfect purity. Virus obtained 
from this locality was therefore far preferable to the saliva, which 
contained quantities of micro-organisms. He later found that the 
virus existed in the whole nervous system of animals and in the 
salivary glands. 

Pasteur next discovered that a given virus had its virulence 
modified by passing it through different species of animals. Inocu- 



H YDROPHOBIA . 465 

lation from monkey to monkey attenuates the virus. Conversely, 
the strength of the virus is increased by passage through rabbits: 
the period of incubation is also shortened, so that by the time the 
one hundred and twenty-fifth passage had been reached this period 
is reduced to seven days. The spinal cords are virulent through- 
out their entire substance, and there is obtained by this method a 
virus of sufficient strength and reliability to be used for purposes 
of inoculation. By cutting up the spinal cord into fragments a 
few centimetres long and suspending them in a dry atmosphere 
their virulence gradually diminishes until it is lost, so that there 
can thus be obtained virus of any desired strength. 

If a dog is to be made refractory to the poison of rabies, it is 
first inoculated with a cord so old that the virus is very feeble. 
The strength of the inoculation is gradually increased from day to 
day, each virus preparing the animal for the succeeding stronger 
dose until cords are used which have been drying only one or two 
days. The dog has now been successfully inoculated with very 
strong virus, and, feeling no bad effects from it, has become refrac- 
tory to the ordinary "street rabies." 

The brains and cords of rabbits used for these inoculations are prepared 
as follows : Having been removed from their bony casing, they are laid upon 
a plate with the basal surface upward. The parts which are necessarily handled 
should first be wrapped in paper. All instruments and utensils used are 
carefully sterilized by heat. The cords are dried by suspending them in bot- 
tles with a hole near the bottom for the purpose of ventilation ; the two 
apertures are closed with cotton-wool plugs, and caustic potash is kept in the 
bottom of the flask to secure a dry atmosphere. On drying, the cords 
become crumpled and brittle and darker in color. The cord is used in pref- 
erence to the medulla, as being more convenient to handle. The virulence is 
the same in both. The emulsion is prepared by beating up fragments of the 
cord about the size of a pea with sterilized veal -broth or with water in a half- 
ounce conical glass, which is afterward covered with filter-paper. The nerve- 
tissue is triturated by means of a glass rod, and the broth is added until a 
thick, turbid liquid amounting to about half a tablespoonful is produced. 
The broth used for this purpose is kept in a pipette bottle. 

The inoculation experiments upon animals are carried out by 
trephining and inserting a drop or two of the emulsion beneath the 
dura mater. In this way absolute certainty of result is obtained as 
well as an exact period of incubation. 

It was in July, 1885, that Pasteur first applied his protective 
inoculation in man. He had at that time rendered fifty dogs 
refractory without a single failure. A hypodermic syringeful of 
the emulsion is injected into the subcutaneous tissue of the region 
of the hypochondrium, as the tissue is here loose and is more 

30 



466 SURGICAL PATHOLOGY AND THERAPEUTICS. 

rapidly absorbent than elsewhere. The patients are first inoculated 
with a cord fourteen days old, and the inoculation is repeated daily 
for nine days, each time with a cord one day fresher. In winter 
the oldest cords used are five days old, and in summer cords which 
have been drying- for four days are also employed. The preceding 
is the ordinary treatment. The so-called "intensive treatment n 
is used for patients who have been bitten on the hands or on the 
hare feet, or for patients who have been bitten so long beforehand 
that it is necessary to complete the course of treatment more rapidly. 

The intensive method consists in the omission of certain cords 
— for example, the weakest — and of some of the intermediary cords, 
and in the administration of the inoculations at shorter intervals 
than once in the twenty-four hours. If the first dose is given at 8 
A. m. from a cord ten days old, the second dose would be given at 
2 p. m. from a cord eight days old; the third at 8 p. m. from a cord 
six days old; and the fourth at 2 A. m. from a cord four days old. 
This series may be repeated at the same intervals, or, if the case 
be desperate — that is, if the patient has been bitten so long before 
treatment that the average period of incubation has already elapsed 
— the inoculation is carried even further, and the virus of only one 
day's drying may be used in the first twenty-four hours. By this 
intensive method it is claimed that better results are obtained than 
by the older, apparently safer, but slower, method. 

The first case upon which this method was tried was Joseph 
Meister, a child nine years of age. He had been severely bitten 
on the hands, the legs, and the thighs, and when rescued from the 
dog was covered with blood and saliva. The animal was undoubt- 
edly mad. Sixty hours after the accident (July 6th) the boy was 
inoculated in the right hypochondrinm with half a syringeful of 
the emulsion of the cord of a rabbit which had died on June 2ist. 
The cord had been kept fifteen days suspended in a bottle as above 
described. On the following day he was injected with a fourteen- 
days'-old cord, and so on daily or twice daily until, on July i6th, 
the thirteenth sitting, he was injected with a cord one day old. 
Healthy rabbits were inoculated with each preparation, and it was 
found that the older cords did not produce rabies, but the cords of 
July ii, 12, 14, 15, and 16 were all virulent, and the disease was 
therefore reproduced; Meister survived. 

A child of ten, who had been bitten in the axilla and on the 
head, and who was not subjected to treatment until thirty-seven 
days after the accident, died of hydrophobia appearing eleven 
days after the end of the treatment. The question arising which 



HYDROPHOBIA. 467 

of the viruses had killed the child, that of the mad dog or that 
prepared by Pasteur, her skull was trephined near the wound and 
a portion of cerebral matter was taken out and inoculated into 
rabbits, which died fifteen days later. Had the deaths of the 
rabbits been the result of the preventive inoculations, the incu- 
bation period would have been only seven days. 

Of those who succumbed after treatment the majority were chil- 
dren who had been bitten in the face and who had only received 
the simple treatment, which Pasteur does not now consider suf- 
ficient for such cases. For those he now uses the intensive treat- 
ment, giving three or four inoculations daily, and reaching the 
one-day-old cord on the third day. Three courses are given 
during a period of ten days. 

The difference in virulence of the cords is not considered by 
Pasteur to be due to a diminution of degree, but to a diminution 
in quantity of the virus contained in them. He is inclined to 
believe that the rabies virus is made up of two distinct substances 
— the one living and capable of multiplying in the nervous sys- 
tem; the other not living, but capable, when present in suitable 
proportions, of arresting the development of the former. In other 
words, he believes in a "vaccinal" matter associated with the microbe, 
the latter dying more rapidly in the dried cords than the former. 

Vaccine inoculation for protection from small-pox is sufficient 
if performed three days after exposure, as the period of incubation 
of the vaccine is only nine days, while that of small-pox is twelve 
days. So with the vaccine of rabies: it must be given sufficient 
time in order to do its work more effectively. 

The death-rate, according to French statistics, amounts to 30 
per cent, after efficient and early cauterization. When these pre- 
cautions are not used it rises to 80 per cent. According to Gowers, 
when no preventive measures are adopted at least half, perhaps 
two-thirds, of persons bitten escape. A moderate estimate of the 
death of all persons bitten by rabid animals except wolves is prob- 
ably 20 per cent. , whether the bites have been cauterized or not. 
The death-rate from wolf-bites is as high as 65 per cent. , and when 
the face and head are bitten it reaches 88 per cent. Indeed, in 
Russia it is believed that every person bitten by a mad wolf dies. 
The incubation period following the bite of this animal is quite 
short, owing to the number and the nature of the bites. It is not 
probable that there is any difference in the viruses of a mad dog 
and a mad wolf. 

The results obtained by the work as carried on in Paris at the 



468 



SURGICAL PATHOLOGY AND THERAPEUTICS. 



Pasteur Institute since the beginning of the employment of this 
method are summarized and discussed very carefully and fairly in 
the Annales de V Institul Pasteur. All cases are placed in one of 
three categories: Class A consists of those bitten by animals shown 
to have been rabid by experimental inoculation; Class B consists 
of those bitten by animals declared to be rabid by veterinary 
authority; Class C includes those bitten by animals supposed to 
have been rabid. The following table gives the figures of these 
different classes for 1893: 



Bites of Head. 


Bites of Hands. 


Bites of 


Body an 


d Legs. 


Total. 






























£c 












£g 






>>c 


























e 






c 






c 






c 




'^u 


.22 


T3 


U V 


,22 


H3 






T3 




.a 


X) 




« 




p, 






0. 




.2i 


p. 




.22 


p, 


Ph 


Q 


s 


P-> 


ft 


S 


P< 


Q 


s 


Ph 


Q 


S 


A, 12 


O 





80 








40 








132 


O 





B, 89 


O 





534 


3 


0.56 


385 








IO08 


3 


0.30 


C, 34 


O 





243 


1 


0.41 


23I 








508 


1 


0.20 


135, 






*V, 


4 


0.46 


656, 






1648 


4 


0.24 


Total. 






Total. 






Total, 













The statistics for each year from the beginning up to the present 
time are given below: 



Years. 



886 

887 

888 .. . 

889 

890 

891 

892 

893 

Total 



Patients Treated. 



2,671 
1,770 
1.622 
1,830 
1,540 

1,559 
1,790 
1,648 



14,43° 



Died. 



25 
14 

9 

7 
5 
4 
4 
4 



72 



Mortality, per cent. 



O.94 
O.79 

o-55 
0.38 
0.32 
0.25 
0.22 
0.24 



0.50 



These figures apparently afford ample proof of the success of the 
Pasteur method. 

Tizzoni has experimented with a protective substance produced 
by treating the cords of infected rabbits with peptones. An emul- 
sion of the cords in peptones parts with its virulence entirely in 
twenty-four hours. The flocculent deposit obtained is preserved 
in glycerin. Tizzoni has been able not only to render rabbits 
immune, but also to check the symptoms of rabies after they 
had already developed. This method of treatment has not yet 
been applied to man. (See Appendix.) 



XX. ACTINOMYCOSIS. 

Actinomycosis (axn'c, ray, /zwoyc, fungus) is an affection charac- 
terized by the presence in the tissues of a vegetable parasite (acti- 
nomyces) which gives rise to a chronic inflammatory process. This 
disease is found both in animals and in man. In the former it 
gives rise to a granulation or sarcoma-like tumor, and it has been 
described, before its true nature was understood, under a variety 
of names, such as "big jaw," "swelled head," and "lumpy jaw." 
Many cases described as sarcoma in cattle were undoubtedly forms 
of this affection. In man the growth is accompanied by a suppu- 
ration, which is not due, however, to the organism, but to a mixed 
infection with pyogenic cocci. 

Langenbeck was one of the first to notice the presence of the 
parasite in a case of vertebral caries. Lebert was, however, the 
first to publish, in 1848, a description of the same organism, which 
he found in an abscess of the thorax. He did not, however, recog- 
nize its significance. Robin observed similar bodies also in pus, 
and Rivolta in 1868 and Perroncito in 1875 found the organisms in 
the jaws of diseased cattle. The first scientific description of these 
organisms came from Bollinger, Israel, and Ponfick in 1877, I ^7^> 
and 1879, respectively. Since then a large number of cases have 
been observed and described in man. In America, Belfield first 
recognized the parasite in cattle, and Murphy reported the first case 
of actinomycosis hominis. According to the latter, up to January 
1, 1891, there had been reported two hundred and fifty cases of the 
disease in man. 

A description of the organism will be found on page 76. It 
may be briefly stated here that the organism is known as actino- 
myces, or the ray fungus, and it appears in pus or on granulations 
as minute granules varying in size from a grain of sand to a pin's 
head (Fig. 22). These granules, which are yellow in color, are 
easily seen by the naked eye. If pressed down with a cover-glass, 
they readily flatten out, while possibly a distinct gritty sensation is 
transmitted to the finger, owing to the presence of calcareous mat- 
ter. With a low power of the microscope the fungus will be rec- 
ognized scattered over the field in the form of irregular patches, 

469 



47° SURGICAL PATHOLOGY AND THERAPEUTICS. 

which might at first be mistaken for granular debris, but which, 
by more exact examination with a higher power, will be observed 
to have the characteristic appearance. The rosettes of clubs min- 
gled with pus-cells and fragments will then be found. By pressing 
upon the cover-glass the rosette is broken up and the club-shaped 
masses are seen separately. If the yellow granule is picked apart 
in water, the central portion of the fungus appears to be a struc- 
tureless core. 

Cultures of actinomyces are made with great difficulty. Agar- 
agar and egg-albumin, blood-serum, bouillon, and gelatin are the 
media used for the purpose. The growths taken from plates and 
grown in blood-serum develop at the end of four or five days. 
According to Babes, cultures obtained by him grew mostly in the 
depths of the culture medium and rarely on the surface. Attempts 
to transfer the actinomyces from one animal to another by mixing 
them with the animal's food have not succeeded, but inoculations 
have successfully been made by introducing the granules into the 
peritoneal cavity of rabbits ; also by introducing the infective mate- 
rial beneath the skin, into the veins, and into the abdominal cavi- 
ties of calves. The cow appears to be the most susceptible of all 
animals. Although the disease is found in cattle, yet in reported 
cases it does not appear that it has been transmitted to man in his 
food, and the disease has not been observed in carnivorous animals. 
The few observations that have been made, tending to show that 
the meat of animals is the source of disease in man, have not suf- 
ficed to demonstrate this satisfactorily. Hence it has not been the 
custom in many places to condemn the entire animal when a part 
only is affected. There are no observations which prove that it can 
be transmitted by milk. According to Bostrom, who carefully 
analyzed a series of cases, the disease appears to begin in the 
autumn, and the ears of grain in which the fungus probably grows 
are the carriers of the disease to man and to animals. In one of 
this author's cases the patient acknowledged that he was in the 
habit of chewing ears of barley or of rye, and in the much-quoted 
case of Soltmann the patient, a boy, swallowed an ear of barley, 
which caught in the oesophagus and could not be coughed up. 
Perforation occurred, and mycotic abscesses formed around the 
vertebral column and elsewhere. Johne found frequently in the 
tonsils of hogs ears of grain containing unmistakable growths 
of actinomyces. Jensen observed an outbreak of the disease in 
cattle due to feeding them with grain which had been taken from 
a soil reclaimed from the sea. It seems probable that the most 



ACTINOMYCOSIS. 471 

frequent route of infection is the mouth and the pharynx, the 
organism becoming attached to and growing in some of the 
numerous inflammatory processes common to this region. The 
cavities of carious teeth and the follicles of the tonsils appear to 
be localities that afford a soil favorable to the growth and develop- 
ment of this organism, from which foci it is subsequently distrib- 
uted throughout the system. After once having gained a foot- 
hold, the parasite is said to be conveyed to distant parts of the 
body through the blood-current and not through the lymphatics. 

In man the disease presents two salient features — the formation 
of abscesses and the presence of yellow granules in the pus, and 
granulations of these abscesses. The swelling does not have a 
well-defined border, as seen in cattle, in which it resembles a 
tumor, but it is more or less flattened and disseminated, and is 
accompanied by the growth of an indurated connective tissue 
which is very characteristic. There is usually, later, a false 
fluctuation at certain points, due to the presence of the soft, 
fungous mass of granulation tissue. Presently the skin becomes 
a deep red and the abscess opens. The granulating surface has a 
yellowish or a violet color. Pressure brings a small quantity of 
thin sero-purulent or cheesy material. In some cases a few drops 
of thick pus will ooze out after lancing the abscess, and with them 
a number of striking sulphur-colored granules. On probing a sinus 
thus formed it will be found that the disease has involved the adja- 
cent muscles, which are so infiltrated and matted together as to 
impede their movements. The nerves are also involved in the 
induration, and in later stages the bone becomes affected and in 
it cavities form. The jaw is usually the part most frequently 
attacked, and later the teeth drop out and the pus-cavity com- 
municates with the mouth. In the mean time new fistulae form 
and communicate with the original focus. The disease does not 
attack the interior of bone as in cattle, forming a spina ventosa, 
but rather confines itself to a multiple caries with the formation 
of osteophytes (Partsch). 

If the inflamed mass is laid open at a post-mortem examination, 
the sinuses are found to resemble those seen in connection with 
tuberculosis of bone. There is a lining pyogenic membrane com- 
posed of fungous granulation tissue of a yellowish or a reddish- 
gray color, which tissue is readily scraped away. A central pus- 
cavity is rarely found. A number of minute abscesses, however, 
are seen in the walls of the inflamed mass. Other abscesses may 
be found in the immediate neighborhood, either entirely inde- 



472 SURGICAL PATHOLOGY AND THERAPEUTICS. 

pendent of the original focus or communicating with it by fis- 
tulous tracts. The yellow grains are to be found in the secretions 
of all these various cavities and also in the walls. 

A cross-section of the abscess-wall shows it to consist of a sar- 
coma-like tissue. It has been said to resemble so closely round- 
cell sarcoma as to be almost indistinguishable from it were the 
yellow grains absent. In other places spindle, epithelioid, and 
giant-cells are seen. In the peripheral portions of the disease 
the abscess-wall consists of a dense fibrous tissue surrounding a 
cluster of cells, in the centre of which is the actinomyces (Babes). 

When once the parasites begin to develop in the tissues a growth 
of sarcomatous connective tissue is built up around them, forming a 
barrier which probably tends to retard their growth. The cells near- 
est the centre of this nodule undergo fatty degeneration, and break 
up and leave a more or less fluid substance in their place, and in 
this way .a miliary abscess is formed. Large abscesses form by 
fusion of several smaller ones. 

The progress of the disease is slow, as the inflammation is of a 
chronic type. Infection takes place most frequently through the 
mouth and the pharynx, but the organism may find an entrance to 
the system through the air-passages or through the skin. In any 
case a wound, however small, is necessary for inoculation to take 
place. 

When infection takes place by the mouth in the less severe forms 
of the disease, the patient comes with a history of toothache, with 
swelling at the angle of the jaw, and with difficulty of swallowing 
and of opening the jaw. The external tumor reddens and softens, 
and fluctuation is followed by an opening and discharge of pus 
containing the characteristic yellow granules. After some tem- 
porary improvement the swelling continues to spread and the 
abscess opens into the cavity of the mouth. Many cases can be 
arrested at this point by a radical operation which removes the 
entire diseased mass. A very characteristic symptom, according 
to Partsch, is the rigidity of the jaw caused by the induration of 
the surrounding muscles. 

If the affection is allowed to continue untreated, however, the 
bone of the lower jaw becomes involved, the teeth drop out, and 
several of the adjacent muscles are destroyed. As the disease 
works its way downward it follows the line of the sterno-mastoid 
muscle to the clavicle, involving on its way nearly all the struc- 
tures of the neck, including the vessels. The pus, which burrows 
about inside the diseased mass, finds its way to the surface at vari- 



ACTINOMYCOSIS. 473 

ous points in the neck, and even into the oesophagus, so that food 
may be discharged through the fistulse. A muco-purulent expec- 
toration from the lungs shows that the disease has reached these 
organs, and on its way it may have destroyed the clavicle. If 
portions of the fungus find their way during this process into the 
circulation, the heart may become involved in the disease, and 
small tumors may form in the substance of its walls and in the 
pericardium. Metastatic deposits may be found in the spleen, the 
liver, the brain, and the kidneys. 

When the upper jaw is the seat of the disease the prognosis 
seems to be still more unfavorable. Here the cheek is involved in 
the inflammatory process, and abscesses may form and break as 
high up as the lower eyelid, which probably will be very much 
swollen and oedematous. Here also the disease appears to begin in 
a carious tooth. With the discharge of pus there may be symp- 
toms of nasal catarrh, showing that the disease is spreading in the 
direction of the nose. The swelling soon involves the whole 
cheek, and then spreads backward to the region of the ear and the 
temple. The jaws are often difficult to open at this stage, and the 
fetor of the breath may be well marked. If an inspection of the 
throat can be made, the tonsil and the fauces are often found swoll- 
en and red; the gums are also swollen, and many of the teeth are 
loose. These changes follow one another slowly, and there are 
periods when the disease, after surgical treatment, appears to be 
improving; but although, superficially, there is a diminution in 
the severity of the symptoms, there is a gradual spread of the 
infection in the deeper parts, where nothing seems to be allowed to 
stand in the way of the progress of the disease. In working 
upward it may penetrate the base of the skull and the membranes, 
and even invade the brain itself. From the pharynx or oesophagus 
it may reach the posterior mediastinum, and so affect the bones of 
the spine that they appear to have undergone an extensive caries. 
Abscesses forming in this locality may perforate the intercostal 
spaces and may break externally in the dorsal region. In rare 
cases the disease may begin with an infection of the tongue: 
Hochenegg reports such a case. The patient was a young man 
who looked after cattle and who was in the habit of chewing ears 
of grain. On one occasion he thought he had wounded his tongue 
with the edge of a carious tooth. Two months later there was a 
swelling in the right half of the tongue about the size of a cherry. 
This swelling was excised with a wedged-shaped piece of the 
tongue, and the patient was cured. 



474 SURGICAL PATHOLOGY AND THERAPEUTICS. 

Infection through the respiratory tract is supposed to be due to 
the inhalation of colonies already forming in the mouth or the 
throat. A case is reported in which a tooth was inhaled into the 
lung and became the starting-point of the disease in that organ. 
The direct infection of the lung by inhalation is doubted by many, 
but cases are reported in which it is probable that the fungus or its 
spores were inhaled directly into the lung with the inspired air. 
The left lung is said to be more often affected than the right. The 
first symptom of the disease may be a pain in the side ushering in 
an attack of pleurisy. In a case reported by Bostrom there 
appeared soon after the pain a redness and swelling at the level of 
the eighth rib. On making an attempt to excise this swelling the 
tissue was found to be almost of sole-leather hardness, but pus 
eventually was reached. This inflammatory induration gradually 
spread up and down, so that six months later, when the patient 
died, it had invaded the thorax-wall and had worked its way 
through the diaphragm into the liver and along the spinal column 
to the pelvis. The expectorations in this case were peculiar, and 
were regarded by Bostrom as pathognomonic of the disease. On 
washing the muco-purulent sputa in water they were found to be 
branched in a way that showed them to be casts of the finer bron- 
chi, and to contain the actinomyces granules. This author ob- 
served the same condition of the sputa in another case. 

The effect upon the lung parenchyma is to produce a prolifera- 
tion of round cells which undergo fatty degeneration. Patches of 
pneumonia and peribronchitis are thus formed, or, if the infection 
is near the surface of the lung, pleurisy may develop. Abscesses 
eventually form which break into the bronchi. The apices of the 
lungs are usually unaffected. There is considerable resemblance 
in the clinical course of the disease to chronic or fibroid phthisis. 
At the autopsy the tissues about the diseased part are found to be 
exceedingly dense, beneath which are found abscesses opening into 
the pleura or into a pulmonary cavity. It would be difficult, says 
Babes, to distinguish the disease from tuberculosis of the lungs 
were it not for the presence of the yellow granules. There is often 
great contraction of the thorax when the disease has existed for 
some time in that cavity. 

Intestinal actinomycosis is due to the swallowing of the organism 
with the food. Colonies are said to form upon the epithelium of 
the intestinal wall, and there follows infiltration of the deeper 
layers. The mucous membrane may in this way become covered 
with white patches, and in such cases small nodules, about the size 



ACTINOMYCOSIS. 475 

of a pea, may be found in the submucous tissues. In the mucous 
membrane these nodules soften and form ulcers which may 
eventually perforate into the peritoneal cavity. In a case reported 
by Bostrom such a complication resulted in the formation of two 
abscesses — one in each iliac fossa — that broke and discharged exter- 
nally. At the autopsy it was found that the left abscess had in- 
volved the ovary. Murphy reports a case of a large abscess in 
which the spleen was floating, and which probably was caused 
by actinomyces. Several cases are mentioned in which the pro- 
cessus vermiformis has been found attached to or opening into an 
actinomycotic abscess. The fungus may be found, in cases of 
intestinal actinomycosis, in the evacuations. The symptoms of 
the intestinal form of the disease are those of acute catarrh fol- 
lowing a digestive disturbance with diarrhoea in recurring attacks. 
The complications are those of chronic localized peritonitis. 

Invasion through the skin occurs occasionally. A number of 
cases are reported of inoculation through trivial wounds and also 
after surgical operations. Partsch describes a case of the develop- 
ment of the disease in the cicatrix which formed after an amputa- 
tion of the breast. Hochenegg records a case of a girl who slept 
in a stable with cattle, and who apparently inoculated a suppurat- 
ing wen of the cheek with the parasite. The same author reports 
an actinomycotic abscess of the abdominal walls due to the blow 
of a hammer. Many cases are reported in which the source of 
the infection could not be detected. A striking example is the 
primary actinomycosis of the brain reported by Bollinger. 

The prognosis of the disease when it is situated superficially is 
not unfavorable. If the mass is promptly removed the danger of 
return is not great, and a large number of cures have been 
reported. When internal organs become involved the disease is 
almost certain to terminate fatally. It is essentially a chronic dis- 
ease, and the patient may live from one to three years. 

The treatment of actinomycosis consists in an attempt to remove 
as completely as possible the entire mass of affected tissue. In the 
small primary nodules about the neck and the face this removal may 
satisfactorily be accomplished. If the disease has progressed any dis- 
tance downward into the neck, a free incision should be made along 
the line of the sterno-mastoid from the ear to the clavicle, and all 
the tissues should carefully be dissected out. The operation should 
be as thorough, if possible, as that for cancer. Decayed teeth should 
be removed; the bone of the jaw should be cut away or be so laid 
open as to make it possible to scrape away all evidences of diseased 



47 6 SURGICAL PATHOLOGY AND THERAPEUTICS. 

tissue. When it is impossible to excise the mass and leave a clean 
wound, all sinuses should be laid open and followed relentlessly to 
the end, and their walls should be scraped thoroughly with the 
curette. The exposed surface should then be washed with a solu- 
tion of corrosive sublimate. Solutions of nitrate of silver, which 
are supposed to exert a poisonous influence upon the fungus, may 
be injected into suspected nodules in a strength of 1:1500 or be 
applied to the granulating surface of a wound. Internal medica- 
tion appears to exert no influence whatever upon the growth of 
the parasite. 

In a case recently operated upon by Mixter, the first reported case in man 
in Boston, the disease was found to be situated in the neighborhood of the 
umbilicus. The patient was a chVv laborer, fifty-six years of age. He first 
noticed, three months before, a lump in the abdominal wall that had grown 
slightly at the time of the operation. There was on examination an indu- 
rated mass surrounding the umbilicus about the size of a Mandarin orange. 
At the operation the peritoneal cavity was opened, and the growth was found 
adherent to the omentum and intestine. In the interior of the mass removed 
were found cavities containing a thin whitish fluid. On la}ung open the 
growth freely, two fish-bones, the size of knitting-needles in thickness, were 
found. The pus contained opaque white granules which proved to be actino- 
myces. The patient made a good recover}'. 

The disease in cattle has much less tendency to cause suppura- 
tion. In Europe the disease is prevalent in river-valleys and in 
marshes and on land reclaimed from the sea, and it appears to occur 
more frequently in the young than in the old and more often in 
winter than in summer. It appears in the form of tumor-like 
masses without indications of an inflammatory process, and many 
of the cases of " osteo-sarcoma " of the jaw in animals reported 
in former times were undoubtedly cases of actinomycosis. The 
tongue is often affected in animals, and the infiltration of this 
organ is accompanied by the subsequent induration often seen 
in this disease, but which in this case is more marked than else- 
where. The condition known as "scirrhous tongue" (or H0I2- 
zunge, wooden tongue) is thus produced. This disease of cattle 
is not limited to Europe, but it has been found quite extensively 
in cattle in the United States, particularly in the West. 



XXI. ANTHRAX. 

The nomenclature of this disease is somewhat confusing. It is 
known in England as ' ' splenic fever, ' ' and in Germany as MHz- 
brand. In France the term "anthrax " is applied to another affec- 
tion (carbuncle), and " charbon " is substituted. In man the dis- 
ease is known as "malignant pustule" in all countries. Anthrax 
prevails in various portions of Europe, particularly Russia, Hun- 
gary, France, and Saxony. It is known to exist also in Siberia 
and in India. Anthrax does not prevail in the United States, but 
isolated examples of it are occasionally seen in man. It appears 
at times as an extensive and fatal epidemic. Thus, according 
to Gronin, there perished from this disease in Novgorod, Russia, 
alone during four years (1867-70) more than 56,000 cattle and 
528 men. The greatest losses are incurred during the summer 
season. The domestic animals most susceptible are cows, sheep, 
and horses, the ass, the goat, and swine being less often attacked. 
Mice, rabbits, and guinea-pigs are also particularly susceptible, and 
consequently are used in laboratory experiments. Anthrax can be 
communicated only with difficulty to dogs and poultry. The epi- 
demics in animals occur most frequently in swampy regions where 
decomposing vegetable material abounds. Saline elements in the 
soil, combined with warmth and moisture, seem to favor the devel- 
opment of the virus. The disease consequently is found along the 
borders of rivers and in malarial districts. 

The organism which Davaine demonstrated to be the cause of 
anthrax is known as the "bacillus anthracis. " Owing to its size 
it was easily seen with comparatively low microscopic powers in 
the blood, and was therefore the first of the pathogenic bacteria to 
obtain recognition. A description of the organism is given on 
page 70. 

One of the most striking peculiarities of this organism (Fig. 20) 
is the formation, when in contact with the air, of spores which 
have remarkable powers of resistance to the external agencies that 
ordinarily destroy bacteria. These spores do not form in the body 
of the diseased animal, the bacillus here reproducing itself solely 
by division. The organisms are released from the body in the 

477 



47§ SURGICAL PATHOLOGY AND THERAPEUTICS. 

bloody discharges of the animal. It is probable that the milk 
of diseased animals does not contain bacilli, but, as contamina- 
tion is easy by mixture with blood or with dirt, such milk should 
not be used. 

After the death of the animal the liberated bacilli elongate and 
spores are formed. The bacilli are easily destroyed, remaining 
alive but a few days. Fluids containing bacilli can retain their 
infective properties only a few days, unless spores are produced. 
These spores are called "durable spores," owing to their great 
vitality, and they eventually, under favorable conditions, grow to 
rods and long threads: this is the complete cycle of their develop- 
ment. The spores are found in surface soil, or, according to Pas- 
teur, in deeper soil when the animal is buried, and subsequently 
they are brought to the surface by earth-worms. Koch, however, 
does not accept the earth-worm theory. According to him, the 
spores cannot develop at any great depth, as they need a tempera- 
ture of over i8° C, and at the depth of ground at which the ani- 
mals are usually buried the temperature rarely rises above this 
point. 

Karlinski examined the carcass of a sheep dead of anthrax that had been 
dug up by wolves. He found on it a number of snails. Thinking that snails 
might spread the virus, he made a series of examinations which showed that 
the snails were insusceptible to the virus, that the bacilli passed through 
the intestinal canal without diminution of their vitality, and that they re- 
mained eleven days in a healthy condition in the intestine. 

Koch has shown that infusions of hay are not favorable for the 
development of the bacilli, owing to the acidity of the solution. 
The addition of an alkali so neutralizes this condition that growth 
takes place. In localities where epidemics suddenly break out 
there is probably an alkaline soil and a dead vegetation. After 
a damp season with an overflow of the banks of a river a favorable 
culture-fluid is formed, and the growth of the bacilli from the 
spores, which have up to this time been blowing about as dust, 
begins to take place. When once the spores have developed the 
disease is with difficulty exterminated from a neighborhood. 

The organism obtains an entrance into the body in one of three 
ways — namely, by inoculation through wounds of the skin, by 
inspiration through the air-passages, and with food through the 
intestinal mucous membrane. In infected districts the dust of the 
air is filled with the organisms, and this dust is grimed into the hair 
and the hide, whence the bacteria can readily be rubbed into any 
abrasions on the surface of the body. It has been supposed that 



ANTHRAX. 479 

the virus when taken with the food found its way into the system 
solely through wounds of the mucous membrane. It has, how- 
ever, been demonstrated that the spores develop readily in the 
upper portion of the intestine of sheep, but not in the lower 
portion. The bacilli are destroyed by the gastric juice, while 
the spores pass unharmed through the stomach. Food con- 
taining spores was given by Koch to sheep, with the result 
that all succumbed to the disease, whereas portions of the 
spleen of a diseased guinea-pig, containing only bacilli, did not 
affect them. It is probable, therefore, that the organism can 
penetrate the healthy mucous membrane. 

Koch also demonstrated the possibility of infection through the 
respiratory organs. A mouse placed under a bell-glass, where dust 
containing bacilli had been deposited, succumbed to the disease. 

Malignant pustule is the name of the disease as it is found in 
man. It is known also as u wool -sorter's disease," but this desig- 
nation is said by some authors to be given to that variety which is 
unaccompanied with an external primary lesion. 

Infection occurs by direct inoculation into either a scratch, an 
abrasion, or a small wound of the skin in the great majority of 
cases. Individuals who come in contact with the diseased animals 
or with their hides, and operatives who are at work in factories 
where goods made from the hair or the hides of these animals 
are manufactured, are most liable to contract the disease. In the 
neighborhood of Boston the disease has been observed among 
operatives in curled-hair factories and among the longshore-men 
who handle the hides imported from infected districts. The hands 
in this way come in contact with the spores, and inoculation takes 
place later by scratching the skin. The virus may also be con- 
veyed by flies. Infection by the consumption of diseased meat is 
possible, but it rarely happens, as the mucous membrane of man 
is insusceptible. 

Contagion from man to man is also very rare. Koranyi men- 
tions a case of a woman who, while afflicted with the disease, vis- 
ited her daughter at a place where no case of anthrax had been 
known for thirty years. After the departure of the mother the 
daughter developed symptoms of the disease and died. Koranyi 
had never seen a case of inoculation direct from surface to surface, 
as in syphilis. 

The period of incubation lasts from one to three days. The 
most frequent seat of the primary lesion is the face. The first 
noticeable symptom is a sensation of itching, which accompanies 



480 SURGICAL PATHOLOGY AND THERAPEUTICS. 

the appearance of a small red spot or papule resembling closely a 
flea-bite; twelve or fifteen hours later there forms a small vesicle, 
which is not distended, and which contains a brownish or a bluish 
fluid. If the vesicle is not scratched, it gradually dries up and 
forms a scab. The surrounding skin is somewhat reddened, indu- 
rated, and swollen. This change is the precursor of the gangrene 
which follows. The affected area enlarges in depth and width, the 
color darkens, and finally there is formed a black eschar, which, at 
first superficial, gradually involves the deeper layers of the skin. 
This black spot varies somewhat in size from 2 mm. to 2 cm. ; on 
the surface it is hard and dry, and there is no indication of suppu- 
ration. The slight burning sensation which existed during the 
formation of the vesicle now disappears, and the lesion is charac- 
terized by an entire absence of pain. Presently a circle of new 
vesicles forms around the eschar, giving to it the appearance of the 
seal of a ring set in pearls (Bourgeois). In some cases it looks not 
unlike a vaccine vesicle. The vesicles run together, and the fluid 
within them is more or less discolored by the presence of blood- 
corpuscles. In the mean time the surrounding skin may become 
reddened, although it does not always change color. There is con- 
siderable swelling in the immediate neighborhood, so that there 
forms a circular tumor distinctly raised above the level of the sur- 
rounding skin. It becomes later more or less reddened and indu- 
rated, and the so-called " carbuncular tumor" is thus formed. If 
the disease continues to progress, the surrounding parts become 
affected, and an cedematous swelling makes its appearance, which 
may in some cases be very extensive. In a case of malignant pus- 
tule of the neck in a robust young man under the writer's care the 
whole side and front of the neck became so swollen that prepara- 
tions for tracheotomy were made in case dyspnoea should develop- 
The tumor, however, subsided and the patient made a good recovery. 
If the oedema continues, fresh crops of vesicles often appear, 
and the skin becomes more or less affected and the adjacent 
lymphatic glands are enlarged. The development of these local 
symptoms occupies from three to nine days. Finally, a line of 
demarcation forms around the eschar and the slough separates, 
leaving a granulating surface, or cicatrization may take place 
under the scab without any suppuration. According to Raimbert, 
the striking peculiarities of the malignant pustule are the absence 
of pus or sanies in the initial lesion, the absence of pain, and the 
existence of a vesicular areola, not purulent and of limited 
dimensions. 



ANTHRAX. 481 

In less favorable cases the inflammation of the surrounding tis- 
sues is more marked and it assumes an erysipelatous appearance. 
Bullae form which are filled with bloody fluid, and the parts below 
are ecchymosed. Suppuration and gangrene finally supervene. 
Malignant pustule is found almost always on exposed surfaces of 
the body, such as the face, neck, hands, and shoulders. It is very 
rarely found elsewhere. 

In rare cases the eschar may be wanting, and an ©edematous 
swelling is then the only symptom of the local condition. In such 
cases it has been suggested that an internal infection has taken 
place. This swelling may sometimes be very extensive. The 
lips, the eye, the eyelids, the tongue, the chest, and the upper 
extremities may become involved in this oedema. The swelling 
is soft and diffuse, and is without change in the color of the skin. 
It is accompanied by grave constitutional disturbance. 

For a day or two after the beginning of the disease there may 
be no marked disturbance of the general health, and the patient 
may even continue at his work. In some mild forms of pustule 
there may be no fever. At the end of a few days the patient begins 
to complain of malaise, nausea, pain in the muscles, and headache,, 
which symptoms are accompanied with a rise of temperature. In 
severe cases the heart's action is weak and rapid, and there is 
an oppressive anxiety, with rapidity of the respiration. There is 
slight icterus and other symptoms of septicaemia. The prostration 
is very great, and in the last stages of the disease the condition of 
the patient is like that of one in the algid stage of cholera. 

In some cases tetanic convulsions and trismus precede coma. 
When infection takes place through the intestinal canal, the dis- 
ease begins with debility, depression of spirits, and malaise, and 
probably a chill. In addition to these symptoms of constitutional 
disturbance there are symptoms pointing toward the intestines as 
the disease develops. Hemorrhages may occur from the mouth 
and the nose, and vomiting is followed by a bloody diarrhoea. 
Difficulty of breathing and cyanosis, with great restlessness, are 
also seen in this form. An eruption of small phlegmonous or car- 
buncular inflammations often occurs on the skin. The diagnosis 
in such cases is often extremely difficult, particularly in isolated 
cases occurring independently of an epidemic. Microscopic exam- 
ination of the blood or an inoculation of an animal furnishes the 
only conclusive evidence of the disease. 

The pathological appearances are well shown in an examination 
of a section taken from a fresh pustule of three days' duration. 

31 



482 SURGICAL PATHOLOGY AND THERAPEUTICS. 

An eschar is seen situated beneath the epidermic crust and the rete 
mucosum, involving the upper layers of the cutis vera and surround- 
ed at its lower border by a round-cell infiltration. A few anthrax 
bacilli are found in the superficial scab and in the rete. In the 
-eschar the bacilli are very numerous; the papillae are distended and 
filled with them, but they were not found in the hair- follicles, the 
sebaceous glands, or the blood-vessels. The periphery of the 
eschar is occupied by micrococci and other forms of bacteria 
(Straus). At a later stage of development the eschar involves the 
whole thickness of the cutis. The bacilli may be found in and 
near the eschar in some cases for eight or ten days, but not 
always, for the putrefactive bacteria which are found surround- 
ing the eschar appear to have destroyed the anthrax bacilli. 

In two very acute cases reported by Cornil and Babes a post- 
mortem examination failed to show the bacilli in the neighborhood 
of the pustule or in the adjacent tissues. There were no bacilli in 
the blood of the heart nor in the blood of the cutaneous vessels, 
but sections taken from the different organs gave positive results. 
The bacilli were found in the fibrous tissues which accompanied 
the vessels of the lungs and in the subpleural connective tissues. 
A section of the mucous membrane of the stomach showed the 
bacilli crowding the mucous follicles, while but few organisms 
were found in the blood-vessels. 

Rosenblath reported a case of a boy eight years of age who died 
of malignant pustule on the seventh day. An examination of the 
blood and the organs showed the existence of only a moderate 
number of bacilli, and those apparently not in an active state of 
development. The number of cocci found in the blood and in the 
fluid of the peritoneal cavity was very great. 

In intestinal anthrax an examination of the mucous membrane 
showed, in a case reported by Cornil and Babes, oedema and ecchy- 
mosis in the jejunum, as well as ulcers. The mesenteric glands were 
enlarged. The bacilli were found in the blood-vessels, in the tissue 
comprising the bases of the ulcers, and in the mesenteric glands. 
In the Dupuytren Museum there is a specimen of a stomach, taken 
by Verneuil from an individual who died of anthrax, containing 
gangrenous patches and inflammation of the intestine. 

Decomposition of the cadaver begins rapidly. The blood is 
thick, tarry, and shows no tendency to coagulate. There is a 
tendency to hemorrhages in the serous and mucous membranes. 
The spleen is often enlarged and ruptured, but not invariably. 

The prognosis of anthrax in man varies greatly. In general man 



ANTHRAX. 483 

maybe said to be an insusceptible animal; consequently in most 
cases seen in young and healthy individuals in America the dis- 
ease runs a mild course. When the pustule tends to remain local- 
ized and is uninflamed, the general disturbance of the system is 
caused by the toxic products of the organism, but when once a 
general infection of the system takes place the disease in all prob- 
ability will terminate fatally. 

Although occasionally some of the mild cases of malignant 
pustule recover without treatment, it would be unsafe to allow 
any case to pursue its course without interference. The treatment 
should be radical, and it should aim to remove the infected area as 
thoroughly and promptly as possible while it is still localized. One 
of the most effective methods of effecting this removal is excision. 
The knife should be carried well outside the areola surrounding the 
eschar. The wound should then be washed or mopped with a solu- 
tion of corrosive sublimate (1 : 1000), and an antiseptic dressing, or, 
better, an antiseptic poultice, should be applied to the wound. The 
character of the dressing will be determined by the nature of the 
wound. The best substitute for the knife is the actual cautery, 
which should be applied deeply around and beneath the edges of 
the eschar. Small pustules may be treated by the application of 
liquefied crystals of carbolic acid. A small incision would favor the 
deep application of the acid. Larger pustules may be incised freely, 
and be dusted with powdered corrosive sublimate, which favors the 
destruction of the entire mass (Whittaker). 

Cutaneous injections of carbolic acid (from 5 to 10 per cent, 
solution) around the edges of the eschar may arrest the progress of 
the disease, but this form of treatment is less thorough than those 
already mentioned. The employment of toxines may eventually 
be made successfully in the treatment of this disease. Ogata's 
experiments are suggestive in this connection. This author states 
that he succeeded in eliminating immunizing substances from the 
blood of animals insusceptible to anthrax. This substance he 
describes as a ferment which, when injected into animals, acts as 
a curative and a protective agent. The bacillus pyocyaneus has 
been found to exert an inhibitory influence upon the development 
of the anthrax poison, and it is possible that this organism may in 
consequence eventually be employed as a therapeutic agent. Inter- 
nal medication is probably useless when once general infection is 
established, but a liberal and judicious use of alcoholic stimulation 
may enable the system to battle successfully against the generaliza- 
tion of the disease. 



484 SURGICAL PATHOLOGY AND THERAPEUTICS. 

Anthrax in Animals. — The disease may develop in animals 
either with or without local manifestations. The latter form 
occurs more frequently in sheep and cows. It comes on some- 
times with great violence, and it is then known as the "apoplec- 
tic" form. A healthy and robust animal may be taken suddenly 
with convulsions, foaming at the mouth and nose, and may die in 
a few minutes, or it may rally for a time and the attack again begin. 
The breathing is increased in rapidity and is irregular, and the 
heart's action becomes weak and rapid. Symptoms of anaemia of 
the brain show themselves. There is dilatation of the pupils, trem- 
bling, convulsions, foaming at the mouth and nose, and bloody 
evacuations of bowels, and in a few hours the animal is dead 
(Koranyi). The disease may, however, last longer, in which case 
there is a chill with high fever, swelling of the eyelids and the 
nasal mucous membrane, and attacks of colic. This is the true 
splenic fever. 

Anthrax may develop in animals with a carbuncular swelling 
or swellings, which are often seen in horses. They appear as cir- 
cumscribed swellings (hot and tender), which, as they grow, become 
softer, cooler, and less sensitive. If they are deeply situated, the 
skin is not discolored and there is a good deal of surrounding oede- 
ma. In the skin the carbuncle is reddened or dark-colored. Occa- 
sionally the local swelling assumes an erysipelatous character, and 
emphysematous gangrene eventually develops. The carbuncular 
swellings are seen on the head, the neck, the belly, and the extrem- 
ities. 

A. post-mortem examination shows the blood to be thick, tar- 
like, and incoagulable. The vessels of the subcutaneous tissue, 
the mucous membranes, the alimentary canal, and the mesenteric 
glands are distended with blood, and there are numerous blood- 
extravasations which seem to break up the muscular tissues and 
the parenchyma of organs. The spleen is enormously enlarged. 
Its parenchyma is softened to a semifluid mass of a violet or almost 
black color. The capsule at times is ruptured, and the contents 
escape into the peritoneal cavity. The mortality of this disease in 
animals is placed at 70 per cent., and by some authors as high as 
75 to 80 per cent. 

The thorough study that has been given to the organism which 
is the cause of this disease should leave the sanitary authorities no 
excuse for not adopting the most scientific means of disinfection for 
infected districts, for on no other basis can there be any hope of 
stamping out the disease when it has once established itself. 



XXII. GLANDERS. 

Glanders is an infectious disease, characterized by the forma- 
tion of nodules and ulcers in the mucous membranes, principally 
of the nares, and in the skin. It is found in the horse and other 
domestic animals and in man, and it is caused by a specific patho- 
genic organism. The term farcy (farcio, to stuff) is applied to that 
variety which involves the lymphatics and is seen principally in 
the skin. Equinia is a name which has been employed also to a 
limited extent to designate this disease. Its Latin name is mal- 
leus} The French call it morve, and the Germans Rots and 
Wur)n. 

Glanders is found not only in the horse, but also in asses and 
mules, sheep, goats, and rabbits; mice and guinea-pigs are sus- 
ceptible to the disease when inoculated, but mice are not suit- 
able for inoculation-tests, as they are apt to die of septicaemia. 
Dogs are but slightly susceptible. Glanders appears to occur 
among horses in all climates and in all countries. 

According to Virchow, this disease should be classed with tu- 
bercle and syphilis under the general head of granulomata: in many 
respects it resembles these diseases closely, and has often been mis- 
taken for them. The granulation-like tumors which are so cha- 
racteristic are caused by the presence in the tissues of the bacillus 
mallei. This organism was first described in 1882 by Lofner and 
Schiitz, but the organism was also discovered simultaneously by 
Babes and Israel. A description of this bacillus will be found on 
page 62 (Fig. 18). Though always due to the same organism, 
glanders manifests itself in many ways in different individuals, so 
that in an epidemic in one stable dissimilar types of the disease are 
seen in different cases. There may be infection of the lymphatic 
glands or of the nasal mucous membrane, or an inflammation of 
the lung or metastatic abscesses, with general febrile disturbance. 
The attempt formerly made to separate the disease into several 

1 A name given by the ancient Latin writers on veterinary medicine to various diseases of 
the horse. The original meaning is ha??i??ier : the connection is obscure — perhaps from the 
painful and fatal character of such diseases, or from malleus, meaning the mallet of the 
butcher at a sacrifice; also (in the diminutive form malleolus) a fire-dart. The alleged Greek 
word jua/.ig or fiakia is probably a corruption of the Latin. 

485 



486 SURGICAL PATHOLOGY AND THERAPEUTICS. 

varieties should therefore be abandoned. Experiments show that 
the bacilli gain an entrance into the body through slight wounds, 
and that inoculation takes place through scratches and abrasions 
of the mucous membrane of the mouth and the digestive tract. 
Frankel adopts the view that horses acquire glanders by inhala- 
tion, but the nasal symptoms which are so prominent a feature of 
the disease are attributed by Baumgarten to the general systemic 
infection which has previously taken place. The disease can be 
transmitted from mother to foetus in utero. 

Babes and Nocard succeeded in obtaining an infection of 
guinea-pigs through the intact skin, but it is probable that the dis- 
ease, clinically, is not propagated in this way. It is more probable 
that infection takes place through the intact mucous membrane, 
and it appears that infection probably does take place in the horse 
frequently through the air-passages hy the inhalation of the dried 
organisms in the form of dust. In this way glanders may be 
communicated from one animal to another. It is said that glan- 
ders has been transmitted to menagerie animals by feeding them 
with the flesh of diseased horses. Decroix, however, disproved 
this theory by eating with impunity the meat of a glandered 
horse, both cooked and raw. 

In man the usual mode of infection is through some slight 
wound of the hands that is inoculated while grooming or feeding 
diseased horses or while handling the carcasses of dead animals. 
The disease may also be acquired by contact of the virus with the 
mucous membrane of the eye, the nose, or the mouth. This may 
happen by the animal snorting, by which small particles of pus or 
of mucus are blown into the face of an individual in attendance. 

In making experimental inoculations with the secretion, placed 
in contact with the mucous membranes of animals, it has been 
found that considerable quantities of the material are necessary to 
ensure infection. This fact is accounted for by the small number 
of bacilli found in these secretions, they being easily destroyed by 
other bacteria. It is therefore often difficult to recognize the dis- 
ease by a microscopical examination of the discharges from mem- 
branes or from abscesses. 

The disease may also be transmitted from man to animals, and 
in very rare instances from man to man. Cases are reported where 
an entire family, one after another, has been attacked. It said to 
have been communicated by eating from the same dish with a dis- 
eased individual or by drinking from a pail which had been used 
by a diseased horse. 



GLANDERS. 487 

Berard reports the inoculation of a medical student from a 
patient in the hospital, and more than one experimenter has 
fallen a victim to the disease during scientific inoculation-expe- 
riments. Man, in fact, appears to be highly susceptible to the 
disease. 

Glanders in Man. — In 90 per cent, of the cases the disease is 
observed in individuals who come in contact with horses — coach- 
men, horse-dealers, soldiers, farmers, veterinary surgeons, students, 
and blacksmiths. According to Bollinger, only 6 out of 120 cases 
occurred in women, and these for the most part were employed in 
stables or belonged to the families of individuals thus employed. 
The period of incubation lasts from three to eight days (Koranyi). 

There has been a great variety of classifications, which, now 
that the etiology of the disease is understood, it is better to discard. 
The types of the disease, therefore, will simply be divided into 
acute and chronic. 

At the end of the incubation period an inflammation appears at 
the point of inoculation, which inflammation frequently becomes 
severe and assumes an erysipelatous character, and an unhealthy 
ulcer forms. The adjacent lymphatic glands are swollen, and 
running toward them there are frequently red lines, indicating 
accompanying lymphangitis. Around the point of inoculation 
there appear often minute vesicles, which enlarge and become hem- 
orrhagic, and which later suppurate or are accompanied by gan- 
grene of the parts beneath. If the wound has already healed, it 
may reopen and ulcerate. This ulceration may eventually heal 
after a long time, or it may be followed by constitutional symptoms, 
leading to a fatal result without other local manifestations. Con- 
stitutional disturbance is, however, not always present, but there 
are often malaise, headache, and prostration, and more rarely a chill; 
but when the local inflammatory symptoms develop there is a cor- 
responding amount of fever, which gradually subsides as the local 
symptoms improve and the patient recovers. 

In the greater number of cases, however, the disease progresses 
farther. In the severe cases there are prodromal symptoms fol- 
lowed by an outbreak of fever. Nose-bleed is often an accompani- 
ment of the fever; also severe pain in the muscles and joints, par- 
ticularly in the lower extremities, but they may exist also in the 
neck and the chest; usually no swellings are seen at the painful 
spots, but at times there arise (Edematous tumors, nodules, and 
boils, which may, however, disappear with great rapidity. Some 
of these swellings may suppurate and form abscesses. 



488 SURGICAL PATHOLOGY AND THERAPEUTICS. 

After the fever has lasted from six to twelve days an eruption 
makes its appearance. Small papules, isolated or in clusters, form 
on the face, the trunk, and the extremities, and they gradually 
develop into pustules with an inflamed base. These pustules dry 
up or ulcerate while others are forming, and frequently bullae 
appear with hemorrhagic or gangrenous contents. The face now 
begins to swell, either on account of the presence of pustules or 
from the condition of the nose. A dark bluish-red tumor forms, 
which is firm in consistency and which is covered with vesicles, 
presenting an appearance somewhat like that of the anthrax car- 
buncle, The eyelids are swollen and a thin muco-purulent dis- 
charge flows from the conjunctiva. 

At first there is dryness in the nasal mucous membrane, and 
almost always there is hemorrhage. Later there is a feeling of ten- 
sion about the root of the nose and the mucous membrane swells. 
The discharge at first is scanty, and is followed by a thin, tenacious 
bloody mucus, which later becomes a dirty yellow, and which is 
extremely foul in odor. Pustules and ulcers may be seen upon the 
mucous membrane, and perforation of the septum may occur. The 
discharge flows back into the throat, whence it may be expec- 
torated. 

Inflammatory changes also occur in the mouth, the pharynx, and 
the palate. The mucous membrane ulcerates, and the gums easily 
bleed. The breath of the patient becomes offensive; swallowing 
is difficult. In some cases the inflammation extends to the lungs 
and symptoms of bronchial catarrh occur. The expectoration 
strongly resembles that secreted from the nostrils. There may be 
pleuritic pains with difficulty of respiration, and occasionally 
oedema of the glottis supervenes. There is often gastric disturb- 
ance with symptoms of intestinal catarrh, and diarrhoea often oc- 
curs. In the mean time the development of pustules, boils, and 
abscesses continues, and suppuration may extend as deep as the 
muscles or even to the bones. 

These different symptoms do not appear in any regular order. 
During the progress of the disease the patient becomes greatly 
weakened and the fever assumes a typical character. The pulse 
is rapid, but it becomes weaker as the disease progresses. Toward 
the end the skin is cold and clammy, the ulcers are much enlarged, 
and they discharge foul secretions. The evacuations are involun- 
tary, and death may be preceded by coma or by tetanic convul- 
sions. 

The course of chronic glanders varies greatly: it may last 



GLANDERS. 489 

months or even years, and many of the usual symptoms may be 
wanting. The same local changes in cases of inoculation may 
develop as those in acute glanders. In case no obvious primary 
lesion is visible, there may only be vague and ill-defined symptoms 
of debility, combined with recurring febrile attacks and pains in 
the limbs and joints. Presently a cough appears; there is tender- 
ness about the root of the nose, with muco-purulent discharge 
mixed with blood; and the patient may finally waste away with 
symptoms of hectic fever. In many cases of chronic catarrh there 
may be considerable destruction of the septum and of other bones 
of the nasal passages. 

When the cutaneous affections are a feature of the case there is 
less of the nasal catarrh. There are, however, numerous boils and 
abscesses, accompanied more or less with lymphangitis. The 
abscesses may break and discharge thick pus, and finally may heal 
or may remain as sinuses, discharging a thin, foul secretion. The 
favorite seats of abscesses are in the flexures of limbs, particularly 
of the lower extremities, and in the neighborhood of joints. The 
abscesses often become ulcers with everted borders. In addition to 
these abscesses there are often circumscribed or diffused swellings 
which are accompanied with considerable pain, but without much 
change in the skin, and which after a time disappear. The chronic 
form of glanders may continue indefinitely, appear to improve 
greatly, and then perhaps become acute, or the chronic symptoms 
reappear and the patient gradually succumbs to the disease. 

Pathological Anatomy. — The characteristic features of this dis- 
ease in man as well as in animals are the glanders nodules, or the 
so-called ' ' farcy buds, ' ' which are found everywhere on the skin. 
Lesions are found also in the nose, in the subcutaneous and sub- 
mucous tissue, in glands, in muscles, in the periosteum, and in 
bones. 

In the skin the pustules are a characteristic feature. They are 
found to be due to a breaking-down of the corium and to the for- 
mation there of a cup-shaped depression filled with broken-down 
material. Appearing first like a flea-bite, the skin is raised in a 
papular elevation, on the apex of which the pustule develops; 
later the pustules are discolored by extravasations of blood, and, 
when the scales fall off, they may form ulcers. These ulcers evi- 
dently result from the breaking down of minute glanders nodules 
in the true skin. The nodules are seen also in the mucous mem- 
brane of the nose, and the changes here are so characteristic as to 
establish the diagnosis in doubtful cases. There is also catarrhal 



490 SURGICAL PATHOLOGY AND THERAPEUTICS. 

inflammation and ulceration, which condition may extend into the 
antrum and sphenoidal sinuses. In the later stages there is often 
extensive destruction of the bones, and the cranial cavity may be 
invaded, pus being formed beneath the dura mater. 

Miliary nodules and little abscesses are found in the gums, the 
pharynx, the larynx, the trachea, and the bronchi, and there are 
found in the lungs numerous small areas of consolidation, some of 
which have suppurated. 

The muscles also are frequently the seat of nodules. These 
nodules are found in the biceps, in the flexors of the forearm, in 
the rectus abdominis, in the pectoralis, and, finally, at the point of 
insertion of the deltoid. A species of capsule is formed by the 
inflamed perimysium, which capsule encloses nodules the size of a 
pea. Abscesses develop here also, and they may find their way to 
the surface through the skin or they may burrow down and cause 
necrosis of the bone. The synovial membrane is often studded 
with miliary nodules, and the cavity is filled with an exudation. 
The lymphatic glands are less affected in man than in horses. 

There is also a fatty degeneration of the liver, a swelling and 
possibly infarction of the spleen, minute abscess of the kidney, and 
sometimes of the parotid gland. The testicle may become inflamed, 
and nodules with abscesses or fistulae may eventually develop. 

The diagnosis of glanders is often difficult, owing to the 
varieties of the disease and, in many cases, to the absence of an 
external point of entrance. When the constitutional disturbance 
has been profound the disease might at first be mistaken for 
typhoid fever. The presence of the multiple abscesses, both exter- 
nal and internal, makes up a picture which bears a striking resem- 
blance to pyaemia. In both cases the presence of nasal symptoms, 
together with a consideration of the patient's occupation, would 
aid in the recognition of the disease. Some of the chronic types 
with implication of the lungs might readily be mistaken for tuber- 
culosis, and the appearance at the autopsy even might in some 
cases be misleading. In the chronic form of nasal glanders the 
ozcena bears a close resemblance to the later stage of syphilis, and 
in some cases only by a course of scientific treatment might it be 
possible to make a differential diagnosis. The disease, however, 
can definitely be recognized by the demonstration of the bacillus 
and its culture, which on potato is most characteristic. As it is 
often difficult to obtain bacilli in the secretions, recourse must be 
had to inoculation of guinea-pigs in a manner presently to be 
described. 



GLANDERS. 491 

The prognosis of acute glanders is extremely unfavorable, the 
disease usually terminating fatally in from one to three weeks. In 
the chronic form, according to Bollinger, recovery takes place in 
about 50 per cent, of the cases. According to Koranyi, the chronic 
variety, formerly known as "farcy" — that is, the nodular form — 
runs a more favorable course than the nasal form of chronic 
glanders. 

The period of incubation of the disease in animals lasts from 
three to five days. The nasal form of glanders is more frequent in 
horses than in man. In the chronic form the catarrh of the nasal 
mucous membrane is usually one of the first symptoms, and an 
eruption of nodules in the membrane occurs at the same time. 
The disease may at first be confined to one side. An inspection of 
the nares will show the presence of nodules and ulcers. The sub- 
maxillary glands of one or both sides are enlarged. When the 
ulcers form, the discharge becomes purulent, and the disease grad- 
ually spreads from the nose through the air-passages to the lungs. 
Later, nodules or farcy-buds may appear beneath the skin. The 
animals gradually waste away, and they may ultimately die a year 
after the appearance of the first symptoms. 

Acute glanders may occur primarily or it may come on at any 
time in the course of a chronic case. The disease begins with 
some febrile disturbance and with violent inflammation of the 
nasal mucous membrane. In a few days glanders nodules make 
their appearance in the nose, the throat, and the lungs. At the 
same time there is general engorgement of the lymphatic glands 
and lymphangitis. Nodules and cords are felt beneath the skin, 
which in places is cedematous. Swellings may subside suddenly 
and others appear at different points (flying farcy). These external 
symptoms show themselves at first about the head and the neck, 
and later they spread to other portions of the body. The animals 
begin to cough and to grow thin, and after an illness of from eight 
to fourteen days death occurs. The prognosis of the disease in 
animals is most unfavorable. 

In a case of doubtful disease, whether in man or in animals, a 
bacteriological examination will settle the question of diagnosis. 
A small amount of pus from an ulcer or of the nasal secretion is 
spread over a cover-glass and stained by the ordinary method. 
When bacilli cannot be demonstrated in this way in the secre- 
tions, experimental inoculation may be made in animals for this 
purpose. 

Straus recommends an inoculation of the secretions to be 



492 SURGICAL PATHOLOGY AND THERAPEUTICS. 

examined into the peritoneal cavity of guinea-pigs, or to obtain 
cultures from these secretions and then to inoculate the animals 
with these cultures. An inflammation of the testicles shows 
itself in the animal two or three days after the inoculation. 
The skin of the scrotum becomes tense, reddened, and shiny, 
and there is desquamation of the epidermis. An abscess event- 
ually forms. These animals die in from twelve to fifteen days. 
The same symptoms occur after subcutaneous inoculation, but 
somewhat later. 

Kalming prepared a mixture of a pure culture of the bacilli in 
water, and subjected it to a temperature of 120 C. ; it was then 
filtered and injected into horses which were suspected of having 
glanders, and also into healthy horses. In the diseased animals it 
invariably produced a rise of temperature. Preusse and Pearson 
and others repeated these experiments with the same results. It 
may be concluded, therefore, that this substance (inalleiii) possesses 
a diagnostic value. 

The treatment of glanders, in man consists principally in the 
treatment of symptoms as they arise. If a wound is suspected of 
being infected with the virus, it should be allowed to bleed freely, 
and it should then be disinfected with a strong solution of corrosive 
sublimate or of carbolic acid, and be cauterized with the actual cau- 
tery. The external abscesses should be treated on antiseptic prin- 
ciples as far as possible. They should be laid open and thoroughly 
disinfected, and an attempt should be made in this way to arrest 
the progress of the disease. If the initial lesion is taken in time, 
such attempts may prove successful. 

Bayard Holmes recommends thorough curretting, followed by 
swabbing the cavity with a saturated solution of sulphate of zinc. 
The cavity is then packed with iodoform gauze wet in a saturated 
solution of iodide of potassium. Excision of small nodules is 
recommended by him. In a case reported by Holmes a patient 
during two years and a half was anaesthetized twenty times, and 
new foci were opened or old ones scraped out. A permanent cure 
was finally effected. The strength of the patient should be main- 
tained by judicious stimulation. The nasal ulceration may be 
treated by mild antiseptic washes and douches, and the condi- 
tion in the mouth be treated by appropriate gargles. In acute 
cases there is little prospect of doing anything more than to 
relieve the sufferings of the patient. 

The only approach to an attempt at a specific treatment of this 
disease is the employment of the so-called "mallein." It is pre- 



GLANDERS. 493 

pared somewhat after the manner of Koch's tuberculin. Bonome 
prepares mallein as follows: A culture may be made from the blood 
or from the fresh viscera of animals who have undergone experi- 
mental inoculation with the virus, or from glanders nodules. The 
active principle of the glanders bacilli is precipitated by treatment 
with large quantities of alcohol. The fluid is afterward evaporated 
in a vacuum of 35 ° C. This first precipitate is dissolved in water, 
and is sterilized for three minutes at a temperature of ioo° C, and 
is again precipitated and subjected to evaporation. In this way 
Bonome obtained, after the addition of sterilized water, a yellow- 
ish-gray, sometimes whitish, odorless, neutral fluid, which was 
preserved in a sterilized vessel with a 2 per cent, solution of car- 
bolic acid. 

Healthy guinea-pigs were not affected by the drug, but guinea- 
pigs which had been inoculated with the glanders virus were made 
worse by large doses of mallein (10-15 m &-)> but were cured by re- 
peated small doses (0.5 to 1.00 mg.). They thus gradually acquired 
immunity to larger doses. Rabbits wasted away and died from the 
effects of the mallein, their glanders being made worse. It was 
concluded, therefore, that mallein had a therapeutic value for 
guinea-pigs, but only a diagnostic value for rabbits. Mallein 
had only a diagnostic value for horses, producing fever in those 
that were affected with glanders. In guinea-pigs mallein appeared 
to act very much as tuberculin acts. These animals, when healthy, 
reacted to large doses of both drugs in the same way. In the case 
of glanders guinea-pigs react to small doses of mallein in the same 
way that tuberculous guinea-pigs react to small doses of tuber- 
culin, minimal doses of these two drugs having a therapeutic 
value for these animals. 

Bonome experimented also with cadaverin, thymus extract, and 
neurin. When these substances were mixed with cultures of the 
bacillus mallei they appeared to restrict its development, but the 
experiments made on animals do not appear to have been suf- 
ficiently complete. 

Fortunately, epidemics of the disease do not flourish to any 
great extent in America. In Boston there have been six deaths 
from glanders in man during the years 1885 to 1891, inclusive. 
During 1891 there were but twelve cases of glanders in animals 
reported to the Board of Health. The animals were promptly 
killed, and the premises on which they had been stabled were 
thoroughly disinfected by the authorities. In the State of Mas- 
sachusetts the regulations for the control of contagious diseases 



494 SURGICAL PATHOLOGY AND THERAPEUTICS. 

in cattle are made by the Board of Cattle Commissioners, and 
failure to comply with the law is punishable by fine or by im- 
prisonment. 

Epidemics of glanders were in 1887 reported to Washington, 
D. C, from the States of Georgia, Virginia, Texas, Pennsylvania, 
Louisiana, and the District of Columbia; also from Oowala, Chero- 
kee Nation. The Minnesota State Board of Health reports that 
from March, 1885, to April, 1886, it had isolated over 450 horses 
affected, or suspected of having been affected, by glanders. 



XXIII. SNAKE-BITE. 

Among the great variety of bacterial poisons which have thus 
far been studied there is hardly one which can compare in viru- 
lence with the venom of poisonous snakes. It may be regarded as 
the acme of the type of animal poison, which in the rapidity and 
the disastrous effects of its action is without a rival. 

Deaths from snake-bite are not very common in the United 
States, although rattlesnakes are still very numerous in certain 
portions of the country. In India, however, the mortality is 
frightful, which is due partly to the enormous number of ser- 
pents and partly to the careless habits of the natives and to the 
exposure of the person from scanty clothing. 

A series of careful returns compiled by Fayrer shows that in 
1869 the number of deaths from snake-bite in the Bengal Presi- 
dency was 11,416. He estimates that deaths in India from this 
source alone amount annually to 20,000. In 188 1 the number of 
snakes killed for the bounty offered by the British government 
amounted to 254,968. 

According to Yarrow, there are in America no less than twenty- 
seven species of poisonous serpents belonging to four genera. The 
first genus is the Crotalus, or rattlesnake; the second is the Caudi- 
sona, or ground rattlesnake; the third is the Ancistrodon, or moc- 
casin, one of the species of which is a water-snake; and the fourth 
is the Elaps, or harlequin snake. There is also a poisonous lizard 
known as the Heloderma suspectum, or Gila monster. 

In India, of the twenty-one families of snakes known to nat- 
uralists, four are poisonous ; these are the Elapidcs, the Hydroph- 
idcz, the Viperidce, and the Crotalidcs, and they are known by the 
appropriate name of Thanatophidia. 

Among the Elapidse, of which there are five species, is the Naja 
tripudians, or cobra. It is a most deadly snake, and it is found in 
many parts of India. It grows to the length of 5^ feet or even 
more. It is most active at night, but it is often seen moving about 
during the day. It is, like the Ophiophagus, a. hooded snake. The 
Ophiophagus, another species of this family, is probably the largest 
known venomous snake, growing to the length of from 12 to 14 

495 



496 SURGICAL PATHOLOGY AND THERAPEUTICS. 

feet. It is not only very powerful, but is also very active and 
aggressive. 

The Hydrophidse, as their name implies, inhabit the salt-water 
estuaries and tidal streams. They are all venomous, and are very 
poisonous. 

The Viperidae, which are terrestrial snakes, are more poisonous 
than the Crotalidae. The latter genus has not, as has its American 
namesake, a rattle, and it is less poisonous ; it is also a smaller 
snake, measuring about 3 feet in length, the American snake 
reaching at. times the length of 5 or 6 feet. 

The heads of these serpents are so constructed as to admit of a 
large amount of movement in the component bones. The superior 
maxillary bones are united by ligaments only to the intermaxilla- 
ries, and the lower maxillary bones are so arranged as to be sepa- 
rable from one another anteriorly and to permit motion of one side 
only if desired. The mobility of the superior maxilla is essential 
to the movements of the fang, which is firmly attached to it. This 
fang, in the rattlesnake, is sometimes quite large, measuring three- 
quarters of an inch in length. In the cobra it is decidedly smaller. 
In the rattlesnake the fang is somewhat conical and scythe-shaped 
and has a sharp point. It has a deep groove, due to the folding of 
its edge, which gives it the appearance of being hollow. The fang 
communicates with the duct of the poison-gland, which is situated 
behind the eye and beneath the anterior temporal muscle. The 
walls of the duct are supplied with an unstriped muscular fibre 
forming a sphincter muscle, which enables the serpent to control 
the discharge of the fluid. The duct-opening lies at the base of 
the tooth, where it communicates with the fissure in the fang. In 
the pulp-sac in the jaw lie the nerve-fangs, and when the fang is 
lost by a natural process it is replaced within a few days ; but when 
violently removed the new fang does not appear for several weeks. 
When in repose the fang is folded back and covered by a fold of 
mucous membrane which retracts when the fang is erected. 

The amount of venom contained in the gland varies greatly: 
when perfectly fresh and healthy the snake throws out at first from 
ten to fifteen drops. But if the snake has recently excreted the 
fluid, only three or four drops can be obtained from the glands. 
The color of the venom of the rattlesnake varies from pale emer- 
ald-green to orange- or straw-color, and it is more or less glutinous 
in consistency. In the Indian snake it is a clear viscid fluid, solu- 
ble in water and slightly acid in reaction. It is equally virulent 
whether dry or preserved in alcohol or in glycerin. The active 

- 



SNAKE-BITE, 497 

principles of the virus have been found by Mitchell and Reichert 
to consist of two proteids, a globulin, and a peptone. Prolonged 
boiling seems to convert the peptone into a coagulable albuminoid 
which is not destructive to life. 

It is generally supposed that rattlesnake poison, if swallowed, is 
harmless, but, according to Fayrer, the poison of the cobra can be 
absorbed through the mucous membrane, though with much less 
dangerous effect than when it is introduced into the blood: Mitchell 
and Reichert state if enough of the poison is taken into the empty 
stomach death may ensue. According to Mitchell, the venom exerts 
a powerful local effect upon the living tissues, and induces more 
rapid changes than any known organic substance. It renders the 
blood incoagulable, and it so acts upon the capillary blood-vessels 
that their walls are unable to resist blood-pressure, thus allowing 
the corpuscles to escape into the tissues. The swelling produced is 
not due to inflammation, but is due to hemorrhage. The bodies 
of the red blood-corpuscles lose their shape and fuse together into 
irregular masses, acting like soft elastic colloid material. 

Death occurs, according to Mitchell, through paralysis of the 
respiratory centre, paralysis of the heart, hemorrhages into the 
medulla, and possibly from the inability of the red corpuscles to 
perform their functions. Cobra-poison does not produce the marked 
lesion of the crotalus-poison, because it is lacking in globulin. 

Fayrer states that the poison acts through the circulation upon 
the nerve-centres, paralyzing them and thus destroying the vital 
force. The experiments made by him and Brunton also show 
impairment of the respiratory centre. 

According to Feoktistow, whose experiments were performed at 
Dorpat, the poison acts solely on the nerve-centres, and it has no 
effect whatever upon the blood. According to Wall, the symptoms 
of cobra-poisoning are due to a slowly-advancing general paralysis, 
death being caused by convulsions due to asphyxia, the poison 
acting upon the respiration. The effect of the cobra-poison on the 
blood, he thinks, is not great. It will thus be seen that European 
observers dwell more upon the action of the virus upon the nervous 
system and less upon the blood. 

The mechanism by which the act of striking is accomplished, 
and by which the virus is thrown into the system, is thus described 
by Yarrow: " The snake prepares for action by throwing itself into 
a number of superimposed coils, upon the mass of which the neck 
and a few inches more lie loosely curved, the head elevated, and 
the tail projecting and rapidly vibrating. At the approach of the 

32 



49 8 SURGICAL PATHOLOGY AND THERAPEUTICS. 

intended victim the serpent by sudden contraction of the muscles 
upon the convexity of the curves straightens out the anterior por- 
tion of the body and then darts forward the head. At this instant 
the jaws are widely separated, and the back of the head fixed 
firmly upon the neck. With the opening of the mouth the spheno- 
palatines contract, and the fangs spring into position, throwing off 
the sheath as they leap forward. With the delivery of the blow 
and penetration of the fangs the lower jaw closes forcibly, the 
muscles that execute this movement causing simultaneously a gush 
of venom through the tubular tooth into the wound." As the ser- 
pent withdraws his head the fangs are forced more deeply into the 
tissues, and the jaws are finally loosened from their hold by a shak- 
ing movement of the head, which liberates the teeth. The wound 
is inflicted by the rattlesnake, in almost every case, upon an ex- 
tremity. In India, according to the reported cases, the patient is 
often struck upon the shoulder or the neck. 

The symptoms vary greatly according to the severity of the 
wound inflicted. Many cases recover simply because a complete 
inoculation has not taken place, but when the act has thoroughly 
been accomplished in the way above described, and the hypodermic 
injection of a full dose of virus has occurred, the sequence of events 
follow in a characteristic and almost inevitable course. The pain 
in the wound varies greatly. Sometimes it is hardly observed; at 
other times it is described as a sharp, stinging pain. In most cases 
the wound is more or less painful. The puncture is sometimes so 
small as to be hardly perceptible. The succeeding local symptoms 
are swelling, discoloration, and increasing pain. This swelling is 
regarded by [Mitchell as not due to inflammation, as described by 
several writers, but to the effusion of blood. If the progress of the 
poison has not been arrested by a ligature after a period varying 
from minutes to hours, the swelling and discoloration extend up 
the limb, accompanied by severe pain. Vesicles soon form, and 
the disorganization of the tissues is so rapid that the part becomes 
gangrenous if the patient survives long enough. The direful 
effect of serpent-poisoning upon the tissues is graphically de- 
scribed by Lucan [Pharsalia, book ix.), who records the somewhat 
exaggerated stories of Cato's soldiers in their march through the 
Libyan desert. (This passage is also interesting as being probably 
the first occasion in which the peritoneum is mentioned in poetry.) 

Wretched Sabellus by a seps was stung ; 
Fixed to his leg: with deadlv death it hunsr : 



SNAKE-BITE. 499 

Of all the dire destructive serpent race, 

None have so much of death, though none are less. 

****** 

The spreading poisons all the parts confound, 
And the whole body sinks within the wound. 
The brawny thighs no more their muscles boast, 
But, melting, all in liquid filth are lost ; 
The well-knit groin above, the ham below, 
Mixed in one putrid stream together flow ; 
The firm peritoneum, rent in twain, 
No more the pressing entrails could sustain ; 
It yields, and forth they fall ; at once they gush amain. 

The necessity for prompt action was recognized, as is shown by 
the experience of Murrus: 

Along the spear the sliding venom ran, 
And sudden from the weapon seized the man : 
His hand first touched, ere it his arm invade, 
Soon he divides it with his shining blade : 
The serpent's force, by sad example taught, 
With his lost hand his ransomed life he bought. 

(Rowe's translation.) 

The constitutional symptoms of crotalus-poisoning do not appear 
immediately, but after an interval of a few minutes or of hours 
there is prostration of the most severe character. In the case 
of cobra-poisoning a considerable interval of time — one or two 
hours — has been reported before the advent of constitutional dis- 
turbance. There is sometimes reported a feeling of intoxication 
or of elation, but this is rare. Some of the early symptoms are 
probably due to fear. The patient, after walking some distance, 
feels his limbs give way beneath him, and he staggers and falls. 
The skin is bathed in a cold, clammy sweat; the expression is 
anxious; the pulse becomes rapid and feeble. The breathing is 
usually hurried and is more or less labored. In some cases it is 
diaphragmatic. The patient sometimes complains of a pain in the 
chest and a sense of suffocation. Foaming at the mouth is occa- 
sionally observed. Ewart speaks of the breathing becoming slower 
and slower as death approaches, but this is probably in the last 
stages of coma. If the patient lives long enough, the local swell- 
ing and discoloration of the arm continue to increase, and they 
may spread on to the chest and back. 

The pathological changes found upon man after death seem 
chiefly in the brain and its membranes. In Fayrer's cases conges- 
tion of vessels on the surface of the brain is reported, and there 
is occasional softening of the cerebral substance. The latter may, 



500 SURGICAL PATHOLOGY AND THERAPEUTICS. 

however, have been due to a post-mortem change, which would 
occur rapidly in the Indian climate. Fluid was often found in the 
lateral ventricle. The pia mater is reported as engorged in several 
cases. In Horner's case, reported by Mitchell, the brain was found 
to be of a healthy consistence, but so congested that the cortical 
substance was of a deep brown tint. A drachm of transparent 
serum was found in each lateral ventricle. The veins of the pia 
and the vertebral veins were full of blood. In two other cases 
recorded by Mitchell the same conditions of the brain were found. 

In some of Fayrer's cases the lungs were reported as congested, 
and dark sanious fluid was occasionally seen flowing from the 
mouth, but in many the lungs appear to have been quite normal. 
In one of the cases quoted by Mitchell the walls of the trachea and 
the bronchial tubes were congested and the trachea and bronchi 
were full of a frothy mucus. 

As regards the stomach and intestines, congestions of the mu- 
cous membrane were occasionally reported, but more frequently 
they were found to be normal. No pathological changes appear to 
have been found in the great majority of the cases in the liver, the 
kidneys, or the spleen. The blood in almost all cases is found to 
be fluid and non-coagulable. 

The changes in and about the wound vary greatly from infiltra- 
tion by a dirty-brown serum or extravasations of blood to extensive 
disorganization. Fayrer reports in one case that when the left, 
hand was cut into, the muscles were found disintegrated and of a 
dark color, and in the upper arm the muscles were found to be soft 
and infiltrated with serous effusion. In Sir E. Homes' s case, 
reported by Mitchell, a large abscess existed in the arm and fore- 
arm, and the cellular tissue between the muscles had sloughed 
extensively. 

After experimental inoculation in animals Mitchell found the tis- 
sues around the point of injection soaked with extravasated blood, 
and if death had been postponed for some length of time, the tis- 
sues at some distance from the point of injection were also affected 
in this way to a certain extent, but not so extensively. Pro- 
nounced and frequent ecchymoses were found beneath the serous 
membranes, and there was general congestion of the blood-vessels 
throughout the body. The blood coagulated imperfectly, and then 
only after being exposed to the air, " resembling in this particular 
the state of that fluid observed in conditions of asphyxia." 

In no form of disease or injury, except hemorrhage from the 
great vessels, is promptness of action so important. The first thing 



SNAKE-BITE. 501 

to be done is the application of a ligature. Every minute, even 
every second, is of value, because in many reported cases life seems 
to have been saved chiefly by the prompt application of the ligature. 
It must be applied tightly. The clothing, a piece of twine, any- 
thing at hand, should be used for this purpose, and a second liga- 
ture, broader than the first, may be applied higher up on the limb. 
A stick may be inserted into the top of the ligature to twist it, so 
that an improvised tourniquet may be formed. The bites should 
then be laid open and an effort be made by cupping or by suction 
to withdraw the venom from the tissues. A more effective way of 
accomplishing the removal of the virus before it has had time to 
spread is an excision of the part in which the venomous fluid lies. 
A portion at least of the poison is thus certainly removed and the 
dose correspondingly diminished. It is recommended to wash the 
wound with a 1 per cent, solution of permanganate of potash or 
of aqua ammonia. The use of the actual cautery is probably 
more efficient, as it is only by intense heat that the virus seems 
to be destroyed, experiments having showm that the permanganate 
and the ammonia are not to be depended upon to affect its viru- 
lence. It is the custom of Indians and hunters to flash powder on 
the wound for this purpose. An ember of hot coal would be more 
efficient still. 

If the bite is not on an extremity, the injured skin should be 
cut out ruthlessly by any one present. The danger of bleeding 
would probably be slight in any case. Care should be taken 
not to expose the open mouth of a vein or a serous sac to 
the venom. 

The use of stimulants still holds its popularity, and the wmiskey 
cure is to-day probably the one most resorted to in the United 
States. As prostration is one of the most prominent symptoms, 
the use of alcohol is undoubtedly indicated to strengthen the 
flagging heart. It should, however, be given in moderation at 
first, particularly in the young, as it is not improbable that some 
patients have actually succumbed to the heroic nature of the 
treatment. 

As the ligature cannot be allowed to remain permanently for 
fear of gangrene, it must be released momentarily from time to 
time. It is at this period that the alcoholic stimulant will be of 
advantage to sustain the strength of the patient, as fresh doses of 
the venom are thus unavoidably allowed to work into the system. 
A careful watch upon the pulse will be the guide for treatment. 

A great variety of drugs have been recommended from time to 



502 SURGICAL PATHOLOGY AND THERAPEUTICS. 

time, and have eventually proved to be worthless. Lacerda of 
Rio Janeiro found that an injection of a i per cent, solution of 
permanganate of potash into the wound of an animal that had 
been inoculated was an absolute antidote. The remedy has been 
tried with varying success. The use of aqua ammonia has also 
had its advocates, and this drug was at one time supposed to be 
a specific in its action upon the venom. As a cardiac stimulant 
it has undoubtedly done good work, but no more decided benefit 
can now be claimed for it. The gall of serpents, " snake-stones" 
(a fragment of bone washed in blood, dried, and polished), and a 
great variety of other local remedies are mentioned in the litera- 
ture of this subject. 

It is probable that many cardiac stimulants might be used with 
advantage, such as nitro-glycerin, digitalis, and strychnine. Dr. 
Mueller of Sydney, Australia, has recently published a monograph 
advocating enthusiastically the use of large doses of the latter drug 
given subcutaneously, basing his method on Feoktistow's theory 
of the action of the poison on the nerve-centres. He recommends 
that as much as \ a grain of strychnine should be given in divided 
doses, 16 minims of the liquor strychnia^ (P. B.) being injected at 
a time. If under these large doses the symptoms abate or if the 
latter are comparatively mild at first, smaller doses should be 
injected, as -^ or -^ of a grain; but under all circumstances the 
rule that distinct strychnia symptoms must be produced before the 
injections are discontinued should never be departed from. Many 
cases apparently at the point of death seem to have been revived 
and finally cured by this treatment. It has, however, met with 
much adverse criticism in Australia, and has had thus far only a 
very limited trial in India. Calmette has studied the serum of 
animals rendered immune to the venom of serpents. According 
to this observer, animals can be rendered immune in two ways : 
either by repeated injections of venom of full strength in very 
small and gradually increasing doses, or of venom which has 
been modified by combination with chloride of gold or chloride 
of lime. The serum of animals thus treated has also an immun- 
izing and antitoxic action. This action exerts itself not only 
when brought in contact with the venom with which the ani- 
mals in question have been previously treated, but also with the 
poison of other serpents. It was found that the serum of a rab- 
bit that was immunized by cholera virus exerted an antagonistic 
action to the venom of the French viper and that of several Aus- 
tralian serpents. 



SNAKE-BITE. 503 

Calmette found that 4 ccm. of antitoxic serum, injected into 
a rabbit an hour and a half after 1 mg. of cobra-poison had 
been injected into the same animal, was sufficient to save the 
animal. In rabbits which had not received the serum death 
occurred in twelve hours after the injection of 1 mg. of the 
cobra-venom. 

If the poisoned animal was treated with chloride of lime, a cure 
was effected without resort to the serum. The solution, which is 
of the strength of 1 to from 12 to 45 parts of water, should be 
injected in doses of 5 ccm. subcutaneously around the wound. 
From 20 to 30 ccm. of a more dilute solution may be used in 
the same way. This method, when employed twenty minutes 
after inoculation with the venom, saved animals which would 
otherwise have died in two hours. 

Whatever the treatment may be, the patient should be kept 
quiet. All his spare strength should be kept in reserve. He 
should be encouraged and soothed. Hot bottles may be applied 
to the heart, and the general rules for the treatment of shock might 
well be resorted to with advantage. 

It is most important to remember, in estimating the value of 
any particular line of treatment, that a careful estimate of the 
dose of the venom should be made in each case, for in inflicting 
the injury the serpent often fails to accomplish its purpose, and 
only a drop or two of the poison may come in contact with the 
exposed tissues. 



XXIV. TUBERCULOSIS. 

Tuberculosis did not until recently especially interest sur- 
geons, but it now covers a large field in surgical pathology. The 
surgeon has, in fact, more to do with the disease to-day than the 
physician. 

The inoculability of tuberculosis was first recognized in 1826 
by' L,aennec, who became infected by an injury to his finger 
from a saw during an autopsy upon a case of disease of the ver- 
tebrae. Eventually he died of phthisis. 

Villemin in 1865 was the first, however, to demonstrate experi- 
mentally the possibility of transmitting the disease from man to 
animals. He showed that the cheesy products of tuberculous 
inflammation when introduced into the tissues of rabbits and 
guinea-pigs produced a miliary tuberculosis. He, however, did 
not identify the microscopical characteristics of the new formations 
thus produced with tubercle, nor did he undertake to show that 
other products might not produce the same results. Cohnheim 
and others, however, endeavored to show that any cheesy mate- 
rial, whatever its origin, would produce the same appearances of 
tuberculosis when inoculated. 

It was attempted also to produce tubercular nodules by intro- 
ducing different kinds of foreign bodies into the tissues. But, 
although minute tubercles closely resembling the genuine tuber- 
cle were thus produced, yet they did not appear capable of spread- 
ing to distant organs or of being transmitted from one individual 
to another. 

The recognition of the characteristic giant-cells and epithelioid 
cells of tubercle, and of the tendency of the tubercular masses inva- 
riably to undergo cheesy degeneration, helped to throw light upon 
the investigations which were then being made. 

Cohnheim, whose experiments on the cornea enabled him to 
study the development of the tubercle after inoculation, found that 
a considerable space of time intervened between the inoculation 
and the development of the disease — that, in other words, there was 
a distinct period of incubation. 

A great variety of experiments followed. Tuberculous perito- 

504 



TUBERCULOSIS. 505 

nitis was produced by the injection of diseased sputa into the 
peritoneum of guinea-pigs ; infected food was proved to produce 
ulcerations of the intestinal canal and the subsequent involvement 
of the mesenteric glands ; the dried sputa, when inhaled, produced 
pulmonary tuberculosis. The old belief that tuberculosis was 
caused by a weakness of the tissues gradually yielded to the 
conviction that it was a genuine infectious disease. These views 
received their confirmation in the discovery of the bacillus of 
tuberculosis, and in the demonstration by Koch that by it alone 
could the phenomena of the disease be produced. 

Koch's discovery in 1882 fairly revolutionized a great depart- 
ment of surgery. He made his first observations of the bacillus 
of tuberculosis in the expectorations of phthisical patients and in 
sections taken from miliary tubercles. He succeeded, also after 
many trials, in producing a culture of the bacilli on blood-serum, 
his skill as a bacteriologist enabling him to overcome the unusual 
difficulties that surrounded the cultivation of the organisms. With 
these pure cultures he made a series of inoculation-experiments 
upon rabbits, guinea-pigs, and field-mice, introducing the virus 
subcutaneously or into the various cavities of the body, and also 
by intravenous injections, and in this' way he was able to obtain 
acute miliary tuberculosis. The tubercles taken from such animals 
contain large numbers of bacilli, and they are much better suited 
for microscopical examination than the specimens taken from 
human subjects. From these animals, finally, he was able to 
reproduce the cultures, and then to establish fully the identity of 
the organisms with the disease. 

The bacillus of tuberculosis, which is a thin, staff-shaped body 
from 3 to 4/i in length, will be found more fully described else- 
where. The submiliary tubercle is the pathological structure from 
which are developed the tubercular nodules found in diseased organs 
or in tissues. It is composed of a globular mass of small round cells, 
in the centre of which mass is found one or more giant-cells. The 
giant-cells, which are a very characteristic feature of the miliary 
tubercle, enable one to make an almost positive diagnosis even 
when no bacilli have been discovered. The peculiarity in this 
form of giant-cells consists in the arrangement of the nuclei, 
which are found chiefly in the periphery, arranged with their 
long diameters radiating from the centre of the cell. At the 
centre there is more or less evidence of a degenerative process. 
Surrounding this cell are seen one or more large cells rich in pro- 
toplasm, with large nuclei and nucleoli, which are known from 



506 



SURGICAL PATHOLOGY AND THERAPEUTICS. 



their size and appearance as epithelioid cells. According to Cheyne, 
the epithelioid cells are the most characteristic, as they are more 
constant than the giant-cells. They are, in his opinion, more fre- 
quently the seat of the bacilli which lie between them. These 
cells may be derived from the epithelium, as, for instance, in the 
lung, or from the endothelium of a vessel, or from tissue-cells. 
They are more numerous at the periphery of the tubercle. 

The remaining cells of the tubercle are round or are slightly 
spindle-shaped, and the cell-cluster is supported in a fine reticu- 
lum of connective tissue which in some cases is quite dense at the 
periphery (Fig. 76). The bacilli are found scattered here and there 




Fig. 76. — Submiliary Tubercle, showing giant- and epithelioid cells. The prevalence of the 
spindle is probably due to the locality (the tongue) from which the specimen was taken. 

in varying numbers between the smaller cells, and also in the body 
of the giant-cell. In the experimental forms of miliary tubercle 
the bacilli are usually very numerous, and they are then seen, in 
stained specimens, forming an ornamental border near the fringe 
of nuclei in these large cells. Very few are found in the interior 
of the cell. In pathological tubercle in the human subject it is not 
at all an easy matter to find bacilli, and several specimens are often 
searched through with great care before a single bacillus is dis- 
covered. 



TUBERCULOSIS. S°7 

In infiltrating tubercle the epithelioid cells are not collected in 
small clusters, but are seen through the tissue in broad tracts, or 
they are simply scattered irregularly among the other tissue-ele- 
ments. The tissue which is the seat of the infiltration presents 
two chief types — namely, granulation tissue and gray fibrous tissue. 
The latter type shows less tendency to break down (Cheyne). 

The origin of the cells of the tubercle has been a subject of 
much dispute. According to Baumgarten, the cells found in the 
early stages of the development of the tubercle are not leucocytes, 
as has been supposed, but they originate by the process of indirect 
cell-division from the fixed cells of the part, whether they happen 
to be of connective-tissue origin or are derived from the epithelium 
of a gland or from the endothelium of a minute blood-vessel. The 
giant-cell does not develop from a fusion of several epithelioid cells, 
but it is the product of the nuclear proliferations of a single cell. 
Under the moderately stimulating action of the tubercular virus 
the cell does not receive sufficient irritation to undergo prolifera- 
tion. The protoplasm remains, therefore, undivided and increases 
in size, while the nuclei continue to accumulate in large numbers. 
In many cases of very acute tuberculosis, for this reason, giant- 
cells are not to be found. The centre of the cell is without nuclei, 
as the protoplasm has here already begun to undergo that change 
so characteristic of the disease — namely, cheesy degeneration. After 
the virus has thus affected the fixed cells of the part, it produces 
also an irritation upon the walls of the small vessels ; consequently 
exudation takes place, and the tissue is found infiltrated with leu- 
cocytes, but this occurs usually in a later stage of the development 
of the tubercle. 

The reticulum of fibres in which the cells lie is not usually a 
new formation, but is merely the remains of the pre-existing inter- 
cellular substance. As the cell-growth is most active at the centre 
of the mass, and a certain pressure is thus exerted from within out- 
ward, there is seen at the periphery a thickening of this network 
amounting at times almost to the formation of a capsule. In some 
cases the reticulum seems to be formed, at least to a large extent, 
by the processes of the epithelioid cells. The vascular supply is usu- 
ally very slight, the smaller vessels disappearing altogether. The 
consequence is, that the vitality of the diseased mass is soon affected, 
and an anaemic necrosis occurs, which, accompanied by a granular 
disintegration and a fatty degeneration of the cells, produces the 
condition known as cheesy degeneration, which is found in the mid- 
dle of the nodule, and which may gradually extend so as to affect 



508 SURGICAL PATHOLOGY AND THERAPEUTICS. 

the whole mass. The bacilli also appear to exert an influence 
which brings about a chemical change in the cells. The nuclei 
disappear, the cells refuse to take any coloring reagents, and coag- 
ulation-necrosis takes place. The result of these changes is the 
formation of a mass of dead tissue and of cheesy debris in the 
centre of the tubercle. Where this formation is extensive ulcera- 
tion, or even abscess-formation, may take place. Occasionally lime- 
salts may be deposited in these central portions of the tubercle, 
resulting in calcification. The tubercle may be surrounded by a 
well-marked zone of granulation tissue, or the tissue of the tubercle 
may pass into the surrounding tissues without any well-marked line 
of demarcation. A dissemination of tubercle can take place only 
when the original focus is broken down and in a state of ulceration. 
When inflammatory reaction occurs around the tubercle, incapsula- 
tion may take place, and the system may in this way be protected 
from invasion. 

The entrance of the tubercular virus into the body is through 
various channels. The question of the transmission of the disease 
from mother to child through the placenta has been much dis- 
cussed since the discovery of the bacillus. Baumgarten is one of 
the most prominent advocates of this source of the tubercular 
virus, and, according to this investigator, it may be received during 
fcetal life only to manifest itself perhaps many years later. Tuber- 
culosis of new-born infants is, however, an exceedingly rare occur- 
rence, and in the reported cases of early tuberculosis the possibility 
exists of the acquisition of the disease from the breast of the mother 
or in other ways. It is true that there are recorded cases which 
illustrate the possibility of such transmission from animal to ani- 
mal. Cornil reports the case of a fcetal calf whose lung contained 
a tubercular nodule. The foetus was taken from the uterus of a 
tuberculous cow. Inoculation experiments on pregnant guinea- 
pigs have not, however, been successful. 

Hereditary tuberculosis, then, is an occurrence so extremely rare 
that it cannot be regarded as one of the ways in which the disease 
is acquired by the human subject. Many authorities still main- 
tain, however, that a predisposition exists which may have been 
inherited — that in certain families the tissues and fluids of the body 
furnish a more favorable soil for the growth of the bacillus. The 
difference in susceptibility to the virus may be the same in different 
individuals as it is in different kinds of animals. Frankel does not 
accept even this possibility, although he admits that a delicate con- 
stitution and a catarrhal condition of the air-passages, with feeble 



TUBERCULOSIS 509 

respiratory action, would present conditions favorable for infection. 
It is generally found that tuberculous patients have a family his- 
tory of tuberculosis. Certain individuals, however, are peculiarly 
exempt. It is well known that nurses in attendance upon the sick 
in hospitals for consumptives may remain there years without in- 
fection, and that surgeons constantly wound themselves with tuber- 
culous bone without danger. The family physician will tell you 
that in his private practice he rarely sees tuberculosis in healthy 
families. It is probable, therefore, that a predisposition to tuber- 
culosis is inherited by children from their parents, but the disease 
must nevertheless be looked upon as one which is acquired during 
life by infection. 

Probably the most frequent route through which the virus is 
introduced into the body is through the lungs. The durability of 
the organism and its power to retain its vitality in the dried state 
make possible its introduction with the inspired air. The expec- 
torations of consumption, therefore, are a source of danger, as has 
abundantly been shown, not only when injected experimentally 
into animals, but also when allowed to dry upon the carpets or the 
linen. Cornet has shown that the dust of rooms occupied by such 
patients contains an abundance of the bacilli of tuberculosis, and 
Prudden and others have also found them in the dust of the streets. 
If the sputa are preserved in a moist state, the bacilli are im- 
prisoned, and hence do not become a source of danger. 

When introduced experimentally by inhalation, broncho-pneu- 
monia is produced at the extremity of the tubes, and the bronchial 
glands become infected later. According to Bollinger, not every 
tubercular disease of the lung is due to the inhalation of the virus, 
for it may occur there secondarily by metastasis. It is, for ex- 
ample, a well-known clinical fact that caries of the wrist is very 
often followed by pulmonary tuberculosis. 

Contagion may take place also through the digestive tract. It 
may be transmitted from mouth to mouth by a kiss, or by the 
spoon or the glass used by the consumptive. It should not be for- 
gotten that the spatula or the dentist's instruments may, if not 
properly disinfected, become a source of danger to the patient. 
The susceptibility of the mucous membrane is increased by inflam- 
matory processes, such as rhinitis and pharyngitis, and the virus 
may thus be transmitted to the submaxillary and cervical glands. 
The intestinal canal of animals is readily infected by tuberculous 
food. In man is found also primary tuberculosis of the intestine 
from vitiated food. The milk of tuberculous cows is now a well- 



510 SURGICAL PATHOLOGY AND THERAPEUTICS. 

recognized source of danger. Water may also be the vehicle of the 
virus, experiments in Cornil's laboratory showing that the bacillus 
could live seventy days in sterilized Seine water of the ordinary 
temperature. 

Even meat that has been roasted may be a source of danger, for 
the central portions may not have been subjected to a sufficiently 
high temperature. Secondary tuberculosis of the intestine depends 
upon auto-infection, the sputa often being swallowed. The mem- 
brane of the bacillus is sufficiently tough to withstand the gastric 
juice; consequently the bacillus arrives unaltered in the intes- 
tinal canal, where it attacks Peyer's patches and the solitary folli- 
cles. The mesenteric glands are subsequently affected, and tuber- 
culosis of the peritoneum may thus be developed, particularly in 
man. In women, however, the peritoneum is more frequently in- 
fected through the urogenital tract. As the result of such infec- 
tion tuberculous peritonitis occurs. Infection through the skin is, 
according to Bollinger, underestimated, although the bacilli do not 
appear to be able to enter the pores of the skin like the pyogenic 
cocci. Tscherning reports the case of a servant who cut his finger 
while cleaning the spit-cup of his master, a consumptive. There 
formed a small cutaneous ulcer, which afterward became a nodule: 
a few months later the finger and the tendons of the palm of the 
hand became swollen and the cubital and axillary glands were 
enlarged. The finger was amputated and the glands were excised, 
and they were found to be tuberculous. The patient remained 
well. Middledorff reports the case of a man who wounded his 
knee-joint with a cutting instrument, and bound the wound with 
his handkerchief, which probably contained dried sputa. Two 
weeks after the accident the knee began to swell and excision of 
the joint for white swelling was ultimately performed. An exam- 
ination of the tissues showed the presence of bacilli. 

"Anatomical tubercle " is an example of infection received by 
those who are in the habit of handling infected bodies. Cheyne 
reports a case of a student who injured the fold of the nail at an 
autopsy. A wart formed, which remained as an ulcer after three 
years of treatment: an abscess on the back of the hand finally 
formed, and the finger was amputated. Death from tubercular 
meningitis occurred six years after the injury. The oft-quoted 
example of infection of the prepuce in the rite of circumcision 
by the mouth of the operator, who was tuberculons, is another 
instance. 

Certain portions of the body appear more easily infected than 



TUBERCULOSIS. 5 r l 

others: the face and the head are peculiarly liable, and even certain 
organs and tissues appear to be predisposed. Many inflammatory 
skin affections, which are at first purely benign, may subsequently 
become tuberculous. 

No example of infection with tuberculosis during vaccination 
has been reported: it is probable that the bacilli are unable to live 
in the vaccine lymph. Lawrence, indeed, reports two instances 
of remarkable recovery from advanced stages of tuberculosis after 
an attack of small-pox of a virulent type. 

Cases are reported of tuberculosis of the internal organs of gen- 
eration, which cases, it is possible, may have been due to infection 
during coitus. 

A large number of tuberculous diseases owe their origin to 
intravascular infection, the virus gaining an entrance at some 
unknown point. Thus, it may appear first in a chain of glands, 
as in the neck, or in some portion of the osseous system. 

Acute infectious diseases, like measles and scarlet fever, often 
pave the way for tuberculosis. Susceptibility to the disease is not 
the same at all periods of life. Individuals who have been the sub- 
jects of tubercle in youth often enjoy a particularly healthy exist- 
ence in later life. 

The tuberculous process may spread in different ways and by 
different routes. The original nodule may invade the neighboring 
parts by a simple process of growth. Distant portions of the body 
are reached usually through the lymphatic system. The lymphatic 
glands, however, exert a protective influence: they may not only 
retard the advance of the bacilli, but may also be indirectly the 
cause of their destruction. When the last of a chain of glands has 
been traversed the bacilli are conveyed through the thoracic duct 
into the general circulation. A thrombus may form in a vein 
adjacent to a tuberculous nodule, and metastatic foci may be 
established through embolism, or the wall of a large vein may 
become involved by invasion of the virus from a neighboring 
nodule, and bacilli may then be let loose into the circulation. 
They are conveyed eventually to some arteriole or capillary, where 
they become attached to the endothelium, and the conditions 
favorable for the development of a miliary tubercle are established. 
In this way acute miliary tuberculosis may occur. 

The disease may also spread by an invasion of an adjacent 
serous sac, by the growth of the nodule, or by suppuration, and it 
may discharge into the sac. If the integrity of the sac is still 
maintained, it will be in communication with the lymphatic sys- 



512 SURGICAL PATHOLOGY AND THERAPEUTICS. 

tern, and the danger of dissemination will be much greater than 
when the membrane has changed into a wall of granulation tissue 
which has blocked up the lymphatics. When the bacilli gain 
access to cavities lined with mucous membrane, such as the bron- 
chial tubes or the intestines, they pass over long surfaces, increas- 
ing the opportunity for infection. 

Tuberculous affections are apt to be multiple. The multiple form 
may occur in the primary stage of the disease, as in spina ventosa, 
where several fingers are usually involved, or there may be sepa- 
rate infections at different times. A familiar example is that of a 
patient who had scrofulous glands in childhood, later had white 
swelling of the knee, and eventually died of pulmonary tubercu- 
losis. It is probable that in a case such as this the different mani- 
festations have some connection with one another, and that they are 
examples of periods of latency of the disease followed by meta- 
static deposits. 

The original tubercular focus may, however, be absorbed in con- 
sequence of the influence of the inflammatory process which has 
been set up around it. The tubercle becomes encapsuled. The 
cells undergo cheesy degeneration or calcification, and cicatricial 
tissue finally occupies the seat of the tubercle; or ulceration of the 
neighboring parts occurs and the tubercle is thus removed. If any 
bacilli remain behind, there is always danger of a renewal of the 
tubercular process, as the organisms are exceedingly tenacious of 
life, and either they or their spores, if such exist, may be able at a 
favorable moment to begin again an active development. The 
danger of relapse in this disease, therefore, is always great. Mili- 
ary tubercles may be found in nearly every portion of the body. 
They develop readily in the connective tissue, in or around minute 
blood-vessels, in the parenchyma of organs, or on the surface of 
membranes. 

Tuberculosis probably affects more individuals than any other 
form of infectious disease, for it has roughly been estimated that 
out of every five deaths one is due to this cause. Notwithstanding 
a very large proportion of those affected recover their health, it 
will readily be seen that the bacillus of tuberculosis is one of the 
greatest scourges of the human race. 

In 384 autopsies of children who died of acute infectious disease 
in a hospital in Copenhagen between 1884 and 1887, 198 showed 
undoubted evidences of tuberculosis. Almost without exception 
these children had no sign of the disease during life: in all cases 
the disease occurred in the lymphatic glands. 



TUBERCULOSIS. 513 

In the Aledical Institute of Munich, in 500 autopsies on chil- 
dren under fifteen years of age, tuberculous disease was found in 
150 cases. In other words, 30 per cent, of those who died at that 
hospital were tuberculous. Statistics of the autopsies performed 
'upon adults in that city during a period of nearly thirty years, a 
city renowned for the stringent rules in regard to the examination 
of the dead, showed that tuberculosis existed in 29.4 per cent, of 
the cases. It is found, therefore that, although not always the 
cause of death, tuberculosis existed in one-third of those who died 
during a very considerable period of time. 

Tuberculosis of Bone. — One of the commonest of tuberculous 
diseases, and one of great importance for the surgeon to understand, 
is tuberculosis of the bones and joints. Common as this affection 
is, it is nevertheless one which suffers greatly from the ignorance 
and indifference of many who are called upon to treat it. The 
great advance in the knowledge of its pathology has placed the 
surgical treatment on an entirely new basis, and the extent and 
limitations of tubercular bone disease and the possibilities of intel- 
ligent operative interference are not yet fully appreciated. 

Tuberculous disease of bones and joints, in the great majority 
of cases, follows slight contusions and sprains. Spondylitis, or 
Pott's disease, usually occurs, in a susceptible individual, after a 
fall or a sprain. A bruise of the spongy tissue of one of the bodies 
of the vertebrae or of the head of the tibia, or in one of the tarsal 
bones, is followed by a laceration of some of the delicate vessels of 
the spongy tissue, and an effusion of blood consequently takes place 
between and around the cancelli of bone or into the synovial cavity 
of a joint. The result of such an injury impairs for the time being 
the nutrition of the part affected, the circulation does not go on so 
actively, and there is a period during which absorption of the 
effused blood and exudation does not take place. The point of 
injury and the surrounding tissues are momentarily disabled by the 
damage that has been done, and they are in a less resistant state to 
the invasion of bacterial poison. Individuals predisposed to tuber- 
culosis may already have, as has been shown, the seeds of the dis- 
ease temporarily imprisoned in the lymphatic gland. The bacilli 
may reach the injured spot as single organisms floating in the 
blood, and thus find ready access to the extravasated clot through 
the open mouth of the blood-vessels; more rarely they may reach 
the region in the interior of an embolus which may have become 
detached from a degenerating gland that had discharged its contents 
into a vein, or which may have communicated with the pulmonary 
33 



514 SURGICAL PATHOLOGY AND THERAPEUTICS. 

capillaries, and thus have directed the embolus into the arterial 
system. When such an embolus is caught in a terminal artery, 
wedge-shaped infarctions and wedge-shaped sequestra are not un- 
common in the articular extremities of long bones. These light 
forms of injuries are a more frequent source of tuberculosis than are 
more severe accidents. The French government at one time called 
attention to the large number of cases of amputation for tubercu- 
losis of the ankle-joint following sprains, and enjoined special care 
in the treatment of this injury. All writers bear testimony to the 
fact that it is extremely rare to find tuberculosis of the bone follow- 
ing fracture. In dislocation the rupture of the capsule appears 
to be a fortunate circumstance, for the effused blood can escape 
from the articular cavity, which blood would be likely to remain 
for a long time unabsorbed and to furnish a soil for the growth of 
the bacilli — a process which very probably occurs in many of those 
cases of tuberculosis following sprains. The tension is thus re- 
lieved and absorption more readily takes place. 

The majority of cases of bone-and-joint tuberculosis occur in 
children and in youth. According to Billroth, of all the cases 
one-half occur before the twentieth year. This is true of certain 
joints only, for disease of the wrist and of the shoulder is found 
occurring almost invariably in adults. These joints are more fre- 
quently the seat of primary tuberculosis, whereas children are more 
liable to that form of the disease where the lesion is first found in 
the bone and subsequently breaks into the joint. These primary 
nodules often remain in the ends of the bones for a long time 
without giving any indication of their presence, and Volkmann 
has appropriately called this the "prodromal stage of joint dis- 
ease." Hip-joint disease usually begins as a bone disease, and 
this affection is therefore more commonly seen in childhood. In 
youth, males appear to be more frequently affected than females, 
but later in life there does not appear to be any essential difference 
between the sexes. 

It is probable that only a small portion of the tuberculous 
nodules in joints and bones are primary in origin, the majority 
of them being secondary to some diseased gland in the bronchial 
or the mesenteric group, infection taking place through the mucous 
membrane. Landerer examined post-mortem 150 cases of tubercu- 
losis of the bones and joints, and with one or two exceptions found 
tuberculous disease of the bronchial glands that evidently ante- 
dated the bone affection. 

The hereditary tendencies of this disease are shown in the fol- 



TUBERCULOSIS. 515 

lowing hospital statistics: According to Brandenburg of Basle, of 
141 children with tuberculosis and 162 with bone tuberculosis, all 
being under four years of age, 34 per cent, were children of dis- 
tinctly tuberculous parents. Bollinger of Budapest reports 250 
cases of bone-and-joint tuberculosis, in 97 of which either the 
parents or the grandparents were tuberculous. 

A considerable amount of experimental work has been per- 
formed upon animals to demonstrate the tuberculous nature of 
the so-called "scrofulous" bone-and-joint diseases. Watson 
Cheyne was one of the first to perform this work with pure 
cultures of the bacilli obtained directly from Koch's laboratory. 
A number of experiments were made upon goats, the nutrient 
artery of the tibia being injected by entering the tibial artery 
from below and injecting upward, a ligature having been placed 
on the vessel above the point of injection. Three minims of the 
cultures were thus introduced into a young goat, and the animal 
died on the fifty-second day. In about three weeks from the time 
of the injection the ankle- and the tarso- and the metatarso-phal- 
angeal joints began to swell, cheesy deposits being found in the 
lower end of the tibia and the metatarsal bones. The synovial 
membrane of both joints was swollen and gelatinous. The dis- 
ease in the joint appeared to be synovial, the epiphyses being but 
slighly affected. 

Krause performed a large number of inoculations upon guinea- 
pigs and rabbits. The material used was a pure culture of the 
hacillus suspended in a 0.6 per cent, salt solution. The fluid was 
introduced either through an incision in the skin, or an injection 
was made into the peritoneal cavity or into the circulation, as the 
vein in a rabbit's ear. The culture was also injected into the joint 
itself. Immediately after the injection the bones were fractured or 
the joints were bruised and twisted or were dislocated. In the 
guinea-pigs, out of 44 joints thus treated, 15 became tuberculous, 
and the joints of 72 rabbits were treated in the same way, of which 
29 became infected with tubercle. A microscopical examination 
of the synovial membrane showed the presence of large numbers 
of leucocytes in the tubercles, and occasionally epithelioid cells, 
but no giant- ceils. The articular cartilage was rarely affected. 
The number of bacilli both in the joints and in the bones was in 
all cases, as in man, exceedingly small, and this was in striking 
contrast to the great numbers found in tubercle of other organs. 

There appeared to be no tendency to the formation of tubercles 
in the bones and joints when not subjected to trauma. All the 



516 SURGICAL PATHOLOGY AND THERAPEUTICS. 



cases of fracture healed without the slightest trace of tuberculous 
infection at the seat of fracture. In this respect the contrast 
between the action of the bacilli of tuberculosis and that of the 
pyogenic cocci is very striking, for it is a well-known fact that 
when an animal is infected with the latter organisms a fracture 
of the bone will always be followed by suppuration. Tuberculous 
nodules were occasionally found in the epiphyseal ends of the bones, 
but not in any large number of cases. 

It did not appear that the bacilli were disseminated through the 
system in emboli, for an embolus was discovered in only a single 
case. Krause was of the opinion that the bacilli, after being intro- 
duced into a vein, were carried through the vessel, and, finally, 
being taken up by a leucocyte, made the passage through the wall 
of a vein, or in the bruised tissues passed out at the end of a rup- 
tured capillary vessel into an cedematous tissue or a clot which 
offered a favorable soil for their growth. The presence of a wedge- 
shaped infarction of the bone was not observed in any of the cases. 
W. Muller was able, however, to obtain tubercular infarctions in 
bone by injecting tuberculous material into the tibial artery of 
goats. He obtained typical wedge-shaped infarctions. Many of 
them were, however, round or irregular in shape — a circumstance 
which coincides with the shape found occasionally in the human 
subject. 

The disease begins as a tubercular ostitis, and its commonest 
seat is in the centre of the epiphysis or just beneath the articular 

cartilage. Volkmann re- 
marks that these chronic 
tuberculous inflammations 
of bone have a tendency to 
form in the ends of long 
bones near the joint, just 
as pulmonary tuberculosis 
does in the apex of the 
lung. On making a sec- 
tion of the bone the tuber- 
cular nodule appears as a 
well-defined mass of a 
reddish-gray, yellowish- 
white, or pure yellow color 
(Fig. yy). The surround- 
ing bony tissue is usually red and hypersemic, and the trabecular 
may be somewhat thickened. The cancellous spaces are devoid of 




Fig. 77. 



-Tubercular Nodule of the Head of the Tibia 
(Sp. 1456-2, Warren Museum). 



TUBERCULOSIS. 



5 J 7 



fat-cells, and they contain a swollen semi-fibrons material. With a 
magnifying glass the miliary tubercles are seen at the periphery of 
the nodule, its centre being composed of broken-down cheesy mate- 
rial. The size of these nodules varies greatly. As they grow, the 
tubercular virus attacks the trabecular and leads to their absorption, 
and the bone becomes softened and breaks up into a mass of greasy, 
cheesy material containing crumbling fragments of bony tissue. 
When complete softening has taken place, the material of which 
the nodule is composed becomes puriform, and it may be washed 
away, leaving a cavity lined with granulation tissue. 

In case the trabecular have not completely been destroyed, in 
the infected part the cancelli between them will become filled with 
cheesy debris, and as the vitality of the part has been destroyed 
granulation tissue will form around the diseased mass, and absorp- 
tion of the connecting trabecular occurs: the spongy sequestrum 
which has thus formed separates from the living bone. 

These so-called " cheesy sequestra" are quite small, not exceed- 
ing in size that of a walnut, and are more or less globular in form. 
The surrounding bone may become somewhat thickened, and the 
interstices are filled with gray fibrous tissue, or eburnation of the 
bone may in some cases take place (Fig. 78). 
When the nodule has softened completely 
into pus the surrounding bone is either cov- 
ered by a tubercular membrane, which will 
be described presently, or its surface is infil- 
trated with granulation tissue, which usu- 
ally contains miliary tubercles on its inner 
aspect, affording, nevertheless, protection to 
the adjacent bone. These small sequestra 
lie firmly imbedded in a thick layer of blue- 
gray transparent granulation tissue dotted 
with yellow spots. Large amounts of pus 
rarely accumulate around these nodules. 
When removed and macerated the sequestra 
are seen to be round or irregularly-shaped 
bodies, consisting of thickened spongy tis- 
sue, and they differ in this respect from the 
sequestra of osteomyelitis that come from 
cortical bone, and they are consequently 
much denser and have usually sharply- 
serrated edges. 

The sclerosed bone which develops around 




Fig. 78. — Tubercular Abscess- 
cavity, being the point of ori- 
gin of disease of the hip- 
joint (Specimen 1282, War- 
ren Museum). 



518 SURGICAL PATHOLOGY AND THERAPEUTICS. 

the diseased area forms, with the granulation tissue, a sort of cap- 
sule which may arrest the further progress of the disease, and 
such sequestra or pus-cavities consequently may remain a long 
time without giving any sign of their presence. The surrounding 
bone may, however, eventually be invaded by the tubercular 
growth, and the thickened trabecular may be absorbed, but this 
rarely occnrs. 

The tubercles have usually disappeared from the nodule by the 
time the degenerative changes are well established, and it is with 
great difficulty that the presence of bacilli can be demonstrated. 
The difficulty in finding the bacilli is attributed by Cheyne to the 
fact that they are more numerous in the earliest stage of the disease 
and decrease later, or they rapidly pass into the spore stage. It is 
not always possible, he thinks, to stain them. In double staining 
some are found red and others blue, which result is probably due 
to the different stages of development. 

Very small tubercular nodules may be absorbed, the surrounding 
bone throwing out granulations that permeate and destroy the 
broken-down tissues. This action occurs only when the process 
has not gone on to suppuration, but this rarely happens in chil- 
dren. Some of these nodules are of embolic origin, and in this 
case an infarction occurs which, terminating in necrosis, leaves a 
wedge-shaped sequestrum of bone whose base is usually found just 
beneath the cartilage. These infarctions are found in the articular 
extremities of the long bones. In its early stages of development 
the infarction has a gelatinous grayish transparency, and with a 
lens it will be found studded with submiliary tubercles. It is usu- 
ally about the size of a bean, but it may occasionally be as large as 
a pigeon's egg. The amount of suppuration which these sequestra 
cause is very slight: it may, however, be sufficient to dissect off 
the cartilage, and then the base of the sequestrum, being exposed 
to the articular cavity, may become eburnated and polished by 
friction. 

The tuberculous nodules in bone may frequently be multiple. 
Sometimes both ends of the bone may be involved simultaneously, 
or separate bones and joints may be affected. There are certain 
seats of predilection, as the olecranon and acetabulum, the inner 
condyle, or the neck of the femur, where nodules are more likely to 
be found than in other bones composing a joint, but these points 
are not yet well determined by statistics. It rarely happens that 
the tuberculous nodules give rise to secondary nodules or infiltra- 
tions in the surrounding spongy bone. There may be diffused 



TUBERCULOSIS. 519 

miliary tubercles in a bone as a part of an acute miliary tuber- 
culosis, or in cases where the end of the bone has been freely 
exposed in the later stages of an aggravated form of tuberculous 
joint disease. 

Where the confluent masses of tubercle in the centre of a nodule 
begin to break down, there is formed a collection of caseous 
material surrounded bv tuberculous tissue. This material becomes 
infiltrated with fluids and leucocytes, and thus there is produced a 
cavity containing fluid fatty material, fragments of cells, and leu- 
cocytes, around which there is granulation tissue filled with tuber- 
cles; and in this way a tuberculous abscess is formed (Cheyne). It 
seems, at times, to be quite a matter of accident whether the 
abscess breaks into the joint or finds its way by a more circuitous 
route into the surrounding connective tissue. As the tubercu- 
lous masses spread, caseation takes place at different points in the 
wall, and the masses are discharged into the cavity of the abscess; 
but the spread of the abscess is effected generally by what is termed 
"burrowing of pus." This burrowing occurs in various directions, 
and large collections of pus, altogether out of proportion to the 
original lesion, are formed, and are known as cold abscesses. The 
pus which they contain is so characteristic that it can always 
readily be recognized after seeing it once. It is of a pale white 
color, and it frequently contains masses of cheesy material, like 
coagulated casein, sometimes of considerable size, which makes 
the aspiration of these abscesses often a difficult operation. It is 
for this reason called "grumous. nl It has a very thin serum, 
much thinner than that of the pus of acute abscesses. Occa- 
sionally the pus may be mingled with blood, in which case it 
will have a dirty brown color. Not infrequently small bony par- 
ticles are found in the pus, feeling to the finger like grains of sand, 
particularly in abscesses resulting from disease of the vertebrae. 
The presence of the bacilli in such pus is not easy to demonstrate 
microscopically, but on culture the pus of cold abscesses yields a 
quantity of the characteristic bacilli. The pyogenic cocci are 
rarely seen in the cold abscess before it is opened: according to 
many authorities they are never found in them. Rapid rise of 
temperature and increase of hectic fever accompany the infection 
of such an abscess by the pus-cocci when an abscess is allowed to 
break or is opened without the strictest antiseptic precautions. 

The walls of such abscesses have a very characteristic appear- 
ance, being covered by the so-called tuberculous membrane y 

1 From grume, a clot (grumus, a little heap; npu/uat;, a heap of stones). 



520 SURGICAL PATHOLOGY' AND THERAPEUTICS. 

described originally by Volkmann. This opaque membrane is 
several millimetres thick, and is of a violet-gray or a yellowish- 
brown color, and is very feebly vascular on its inner surface, which 
comes in contact with the pus. It contains innumerable clusters 
of miliar\- tubercles, so that it often appears to be formed exclu- 
sively by them. They are supported by a matrix of coagulated 
fibrin. This membrane can easily be scraped off with the ringer or 
even be removed by a stream of water, and frequently during an ope- 
Tation it peels off from the surface in sheets several inches square. 
IBelow this membrane there is found a fibrous indurated tissue which 
separates the abscess from the surrounding healthy parts. This tis- 
sue is the result of a slight reactive inflammation, and it contains 
no tuberculous material. In over a thousand cases examined care- 
fully by Volkmann, on two occasions only did he see the tuber- 
cles invading the surrounding muscular tissue. If on opening an 
abscess ~::h cheesy :::::e:::- the inuscviliir tissv.e is :h'.:::d :: h.r.e 
undergone a cheesy degeneration, the abscess is probably syphilitic. 
In this case no tubercular membrane can be found, and it will not 
be possible to scrape away the wall of the abscess The presence 
of the tubercular membrane is considered by Volkmann as an abso- 
tutely certain diagnostic sign of the nature of the abscess. 

After all the tubercular membrane has carefully been scrape I 
awav one ran generally find in the subjacent layer of light-colored 
indurated tissue a small clump of red granulations. These gran- 
ulations protrude from the mouth of a fistulous opening leading 
either to diseased bone or to a tuberculous joint. Such a fistulous 
tract must be followed up to its source, and then there will be 
found somewhere in the bone a small cavity which gives rise to 
the more superficial suppuration. Only when this cavity has also 
been curetted thoroughly can the surgeon feel at all sure that the 
tuberculous disease has thoroughly been removed. 

When the abscess breaks spontaneously it communicates with 
the surface by an opening, the walls of which are also tuberculous, 
for whenever the tuberculous pus comes in contact with the healthy 
: ssue infection is bound to occur. Cheyne does not accept the Ger- 
man theory, which assumes that a wall of fibrin has been poured 
out around the tubercles. He thinks that the granular material of 
the wall of the tubercular cavity is derived from degeneration of 
the preformed tissue. Many of these abscesses were at one time 
supposed to be formed independently of the original nodule or joint 
disease; consequently they were called i4 peria^ticula^. ,, S :h Ab- 
scesses occasionally do occur as a result of the transportation of 



TUBERCULOSIS. 521 

infected material through the lymphatics to an adjacent area of 
connective tissue, but more careful study of these abscesses, such 
as has been made since the system of thorough curetting has been 
established, reveals the presence of the minute fistulous tract which 
communicates with the original seat of the disease. 

As already pointed out by the writer, the tubercular deposit is 
almost entirely confined to the ends of the long bones, and this 
pathological fact helps greatly in distinguishing between this form 
of disease and the necrosis following acute osteomyelitis ; occasion- 
ally, however, there is seen tuberculosis of the diaphysis or shaft of 
the long bones. When the disease does occur in this locality, it is 
found only in quite young children. Such a case the writer saw 
recently in a boy about four years of age. The presence of a white 
swelling of the knee-joint of the same limb greatly facilitated the 
diagnosis. There were a series of sinuses opening at different 
points along the course of the femoral artery; an exploratory 
operation disclosed the presence of tuberculous granulations, but 
no large sequestrum. This condition is somewhat more frequent 
in the shaft of the tibia, the humerus, and the ulna than in the 
other long bones, and in these cases it is found to be secondary to 
some other tubercular focus, as in the case quoted above. Tuber- 
culous deposits are still more common in the shafts of the shorter 
long bones, such as the phalanges and the metacarpal and meta- 
tarsal bones. Miliary tubercles accumulate in the medullary tis- 
sue, which is gradually converted into the characteristic granu- 
lation tissue; and this tissue, as it grows, absorbs the inner layers 
of cortical bone and accumulates in considerable quantity. Partly 
from this accumulation and partly from a deposition of new bone 
by the periosteum, which is stimulated to a formation of new 
bone, there is obtained the characteristic flask-shaped bone which 
was known to ancient writers as spina ventosa. This name was 
given by them to all affections that produced such distention of 
bone, whether of tuberculous, syphilitic, or other origin: it was 
suggested partly by the cavities left in the distended bones after 
the granulation tissue had broken down and melted away, and 
partly by the appearance of the macerated bones, which appeared 
to have been distended with air. Gradually the surfaces of the 
bones yield at the end of weeks or months, and the thinned cor- 
tical bone is distended more and more by the growth of the gran- 
ulation tissue until here and there it entirely disappears. The 
bones crackle with a parchment-like sensation under the fingers, 
and fluctuation is finally established at one spot. In the mean 



,522 



SURGICAL PATHOLOGY AND THERAPEUTICS. 



tfh 




time the surrounding skin becomes reddened and swollen, and at 
some point softens and breaks down, the characteristic tuberculous 
pus being discharged. These bones may, however, remain for a long 
time in the granulation stage, and they may eventually heal without 
suppuration, so that no trace of the disease is left behind. The disease 
is generally confined to the shaft of the bone, and the neighboring 

joints may remain perfectly healthy. 
Although the epiphyses may also es- 
cape injury, the intermediate cartilage 
will probably be destroyed, and the 
future growth of the bone w r ill conse- 
quently be arrested, or the entire shaft 
of the bone may be absorbed. As the 
result of the destructive changes great 
deformity to the fingers or the toes will 
necessarily result (Fig. 79). 

Among the short bones is found tu- 
berculous disease of the bones of the 
carpus and tarsus both in childhood 
and in adult life. According to Krause, 
disease of the carpus is not so common 
in children. At this period of life the 
disease has less tendency to spread. 

Whether it be that a bone is affected 

ease - i'-ii 

which does not communicate with the 

articular cavity or that an adhesive inflammation shuts it off from 
the other bones, there are often found only a single fistulous open- 
ing and a tendency to heal without operative interference. This is 
particularly true of the carpus. In adults, however, there is a tend- 
ency of the disease to spread from one bone to another. The whole 
wrist is transformed into a spindle-shaped swelling perforated by 
numerous openings. A sound may be introduced in various direc- 
tions without detecting a sequestrum. The disease appears to be 
the expression of a general infection or to be one of numerous local 
deposits of tubercle, pulmonary tuberculosis being already devel- 
oped or soon to follow. 

In the tarsus a sequestrum is rarely found, except in the os 
calcis. This region may be infected secondarily to the ankle-joint, 
or the disease may originate primarily here as a nodule in one or 
more of the bones. It should not be forgotten that the synovial 
membrane may be affected primarily as well as the bones. The 
disease spreads eventually from one bone to another, until the 



Fig. 79. — Deformity from Absorption 
of Phalanx due to Tubercular Dis- 



TUBERCULOSIS. 5 2 3 

whole tarsus is involved. After long duration of the disease the 
trabecular of the spongy tissue are more or less absorbed by a rare- 
fying ostitis, and the bones become so soft that they can easily be 
cut with a knife. The whole ankle becomes transformed into a 
spindle-shaped swelling, from which tuberculous pus is discharged 
through various openings. The fistulse and the skin surrounding 
their mouths are also infected. This disease of the wrist- and 
the ankle-bones usually receives the name of caries of the carpus 
and tarsus. By caries was meant, originally, an inflammation of 
the bone, with solution or ulceration of the bone, for bones so 
affected have, when macerated, the characteristic worm-eaten ap- 
pearance. The term is falling somewhat into disuse, now that it 
is known that most cases of caries are, with the exception of the 
syphilitic forms, due to tubercle. The term "caries" may be 
applied to tuberculosis of any of the bones or joints. 

One of the commonest seats of tubercular disease, especially in 
children, is in the bodies of the vertebrae. Billroth, in a collection 
of autopsies of nearly two thousand cases of caries of different por- 
tions of the skeleton, found that in 35.2 per cent, of the cases the 
disease was situated in the vertebral column. The disease begins 
here, as in other bones, where the growth is greatest; that is, near 
the periosteum and intervertebral substance. It exists, therefore, 
frequently as a tuberculous periostitis. In this form it is found in 
the anterior surface of the bone, just beneath the anterior longitu- 
dinal ligament. Here the vessels, which run into the bone more 
or less perpendicularly to the surface, are surrounded with granula- 
tion tissue, and the absorption of the bone is therefore greatest at 
these points; and when the ligament is peeled off from the verte- 
brae the tuberculous granulations are found adhering to it as small 
red nodules which have been torn away from the bone, the latter 
presenting the characteristic worm-eaten look of caries. 

Less frequently the centre of the bone is affected, and the tend- 
ency to suppuration is then not so great. Two or more foci may 
exist in the same body. Not unfrequently these nodules contain 
sequestra. Primary disease of two vertebral bodies in different 
non-adjacent parts of the spine is rare, though it has been 
recorded. But no extensive destruction of many of the adjacent 
vertebrae from primary disease of one may be said to be the rule in 
Pott's disease (Bradford and Lovett). 

The disease may become arrested in its earliest stages, and in 
this case bone-formation takes place beneath the ligament, and 
ankylosis of the vertebral column at this point will occur. If the 



524 



SURGICAL PATHOLOGY AND THERAPEUTICS. 



nodule extends between the bodies of the vertebrae, the interverte- 
bral cartilage becomes affected. This generally occurs, indeed, at 
an early stage of the disease. In rare instances the intervertebral 
cartilage is affected primarily, and the affection of the bone is sec- 
ondary (Koenig). As the process advances the bodies of the ver- 
tebrae are gradually converted into granulation tissue containing 
cheesy debris and possibly a sequestrum, and the interarticular 
cartilage disappears entirely. The bodies of the vertebrae are not 
only rendered incapable of sustaining the accustomed pressure by 
the growth of granulation tissue, but they are also much weakened 
by a rarefying ostitis, which often precedes the spread of the 
tubercular infiltration. As the disease advances small prevertebral 
abscesses form, which, as the pus comes in contact with the inter- 
vertebral substance, aid in its destruction. The intervertebral car- 
tilage may, however, in rare instances be destroyed by granulations 






m 







mm'fJ : 

1'-^.. '-hi 1 , v \ * 




Fig. 80. — Angular Deformity from Pott's Disease. A tubercular nodule may be seen in 
the arches of the vertebrae (Sp. 1109, Warren Museum). 

without suppuration. As the bodies of the vertebrae yield to pressure 
the characteristic deformity of Pott's disease is produced (Fig. 80). 
The vertebral body may thus be so nearly destroyed that only a 



TUBERCULOSIS. 525 

wedge-shaped mass remains to mark the former site of the bone: 
in this way angular curvature is produced. When several inter- 
vertebral cartilages are melted down and the intervening bodies are 
converted into wedge-shaped masses, the curvature has a more bow- 
shaped outline. The older writers recognized the fact that the 
angular curvature indicated disease of but a single vertebral body 
(Kranse). 

As suppuration goes on the pus burrows at times for a consider- 
able distance, as in the case of the "psoas abscess," so called, the 
pus following the sheath of the psoas muscle in working its way to 
the surface at the groin. Such abscesses originate from tubercu- 
lous disease in the dorsal or the upper lumbar vertebrae. Abscesses 
originating from disease of the lumbar vertebrae may, however, 
point posteriorly in the lumbar region. Retropharyngeal abscess 
is caused by disease of the cervical vertebrae. Abscesses arising 
from the upper dorsal region may involve the pleural cavity, and 
may even break into the lungs; occasionally the oesophagus and 
the aorta are bathed in the pus of these abscesses. Such collec- 
tions of pus may sometimes find their way into the vertebral canal, 
and spread beneath the meninges and bring about a compression 
of the cord. The adjacent ostitis may also set up meningitis, and 
in this case the cord may be compressed by the inflammatory exu- 
dation. As a result of this pressure paraplegia may be produced. 
Pressure of the spinal nerves may occur occasionally as the result 
of connective-tissue growth around the roots of the nerves. During 
the period of convalescence ossification of the bones at the seat of 
the disease may occur as the result of the reparative efforts of the 
periosteal and osseous tissues, and the fragments of the bodies of 
the diseased vertebra may thus become firmly ankylosed. The 
commonest seat of the disease is in the dorsal region; it is found 
also in the upper lumbar region and, less frequently, in the cervi- 
cal region. In rare instances the transverse and spinous processes 
may be the seat of the disease. The flat bones are also the seat of 
tuberculosis, although much less frequently. In the scapula it 
may occur with or without formation of a sequestrum; usually 
there is a carious softening of the part affected. In a case that 
came under the writer's care the caries affected the greater part of 
the scapula. By laying open the various sinuses it was possible to 
curette the bone satisfactorily. 

Tuberculosis of the ribs and the sternum is somewhat more fre- 
quently seen than that of the scapula. It is usually a disease of 
adult life. Tuberculosis or " caries of the ribs," as it was 



526 SURGICAL PATHOLOGY AND THERAPEUTICS. 

formerly called, is either primary or secondary. The latter form 
occurs after empyema, or other suppurative processes in the 
thorax, in individuals predisposed to the disease. 

The general condition of patients with tuberculosis of the ribs 
is usually good: in many cases, however, there is marked anaemia, 
and the prognosis is then unfavorable; but these cases are not com- 
mon. The disease produces in the bone either periostitis or osteo- 
myelitis. In the latter case a red nodule forms in the centre of the 
bone, and later the periosteum participates in the inflammation. 
The trabecular and the cortical portion of the bone are absorbed, or 
if the progress of the disease has been rapid necrosis occurs, and 
there are found sequestra which, however, are usually not large. 
Several foci may be established in one rib or several ribs may 
simultaneously be affected. As the nodules break down suppura- 
tion takes place and the pus endeavors to escape in different direc- 
tions. Usually there forms at the seat of the disease a fluctuating, 
colorless tumor, on opening which tuberculous pus escapes, and 
the walls of the cavity are found to be lined with the characteristic 
tubercular membrane. On scraping this membrane away a small 
opening will be found communicating with the cavity of the bone. 
A careful examination will show that the periosteum is thickened 
and that the shaft of the bone appears to be distended at this point; 
occasionally the bone is destroyed and a complete solution of con- 
tinuity takes place, but the formative power of the periosteum 
usually produces sufficient new bone to preserve the rigidity of the 
part. 

The pus does not point so near the seat of the disease, and it 
may take a most circuitous route to reach the surface. Riedinger 
reports a case where an abscess over the rectus abdominis was found 
to originate from the fifth rib. A fistulous opening over the spinous 
process of one of the dorsal vertebrae the writer found communi- 
cating with a tuberculous cavity of one of the ribs beneath the 
scapula. This patient eventually died of phthisis. If the peri- 
osteum is primarily affected, the disease may spread over a large 
surface of the rib. In some cases the pus burrows inward, but 
it rarely breaks through the costal pleura. A pus-cavity of con- 
siderable size may, however, occasionally be found projecting into, 
but completely shut off from, the thorax. 

Tuberculosis may also affect the cartilaginous portion of the 
rib. The disease takes the form of perichondritis, but it may 
also involve the cartilage, which then undergoes mucous degen- 
eration, and which may be replaced by connective tissue. Tuber- 



TUBERCULOSIS, 527 

culosis of cartilage is an unusually obstinate affection, as parts are 
involved which lie near vital organs and the reparative power of 
the cartilage is feeble. The pathological changes in the sternum 
are very much the same as in the ribs. Owing to the vicinity of 
the heart and the large vessels, the complications may occasionally 
prove alarming. The membrana sterni posterior may, however, 
prove a protection to the mediastinum against the invasion of an 
abscess. 

A case of very extensive tuberculosis of the sternum entered the writer's 
ward some years ago. The patient was in a cachectic condition. Presently 
a hsematoma formed near the site of one of the many fistulous openings, and 
it soon became evident that a hemorrhage was taking place, from time to 
time, from a vessel of considerable size. On etherizing the patient, laying 
open the tumor, and removing the clots, blood spurted from a large artery 
in the interior of the thorax, possibly the internal mammary. The hem- 
orrhage could only be controlled by plugging the cavity. At the autopsy, 
a few days later, extensive amyloid disease of the viscera was found. The 
source of the hemorrhage could not be discovered. The greater portion of 
the sternum was involved in the disease, and perforation had taken place at 
several points, but no extensive collection of pus was found in the medi- 
astinum. 

Ordinarily, these cases of sternal disease present themselves for 
treatment with a small fluctuating tumor over the sternum or with 
a sinus which marks the site of an abscess that has opened and dis- 
charged. These abscesses and sinuses, when carefully explored, 
under ether, are found to communicate with diseased bone. The 
minute opening leading to the bone-cavity may easily be over- 
looked, and in some cases is impossible to find, but tubercular 
abscesses in this locality almost invariably originate from bone 
disease. The opening of the cavity, as is customary with many 
surgeons, is not sufficient to effect a cure. Extensive dissection 
is sometimes needed to expose the tuberculous nodule, and the 
diseased tissue should be removed thoroughly either by the 
curette, the chisel, or the trephine, as the case may demand. 
It is only by such radical treatment as this that a cure can be 
effected. By the older methods of treatment these sinuses usu- 
ally lasted for years before healing, or the patient died of pul- 
monary tuberculosis. In many cases of tuberculosis of the rib 
a cure cannot be effected without resection of the diseased por- 
tion of the bone. The iodoform treatment, which is described 
in another chapter, is adapted to these cases, but it cannot be 
depended upon to effect a cure without operative interference. 

Among other flat bones that are affected are those of the pelvis. 



528 SURGICAL PATHOLOGY AND THERAPEUTICS. 

The most frequent spot is the acetabulum, but the crests of the 
ilia and the sacro-iliac synchondrosis are also points whence cold 
abscesses may originate. Tuberculosis of the cranium is found 
chiefly in the frontal and temporal bone, always excepting the 
bones of the ear and the mastoid process. A mass of granula- 
tion tissue, with possibly a small sequestrum, is found at the site 
of the disease: in either case a perforation of the inner table and 
possibly a slight infection of the dura may take place. The disease 
manifests itself as a fluctuating tumor, which when opened dis- 
charges pus and discloses the pulsation of the brain beneath the 
dura. Syphilis — for which this disease may be mistaken — does 
not have so great a tendency to form abscesses, and it usually 
affects a much larger surface of the bone. 

That portion of the face most likely to be affected is the infra- 
orbital ridge. Disease in this locality occurs usually in children, 
although the writer has seen cases in adults. Suppuration occurs, 
and ectropion and unsightly scars may be the result of a chronic 
suppuration lasting for months. A case of tuberculosis of the 
malar bone caused an extensive suppuration which finally ended 
in ankylosis of the jaw, for which osteotomy was performed a 
year after the old sinuses had healed. 

Tuberculosis of the bones of the nose is usually secondary to 
disease of the mucous membrane elsewhere. It may also result 
from an extension of lupus of the alse or the septum into the 
nostril. Isolated patches of lupus are, however, seen in the nasal 
mucous membrane. It appears as exuberant granulations which at 
times have a typical papillary growth, or as an ulcer. The cartilag- 
inous portions of the nose are more frequently affected with the 
lupous type of tuberculosis. 

Riedel described large tuberculous tumors growing on the car- 
tilaginous septum in adults, and Koenig saw similar growths in 
children. Tuberculosis of the nose may also follow tuberculosis 
of the hard palate, the disease breaking through the floor of the 
nostril. In a case seen a year or two ago the mucous membrane 
of the anterior portion of the hard palate and the adjacent alveolar 
process was in a state of ulceration which had already extended 
into the nostril. Several members of the patient's family were 
tuberculous. The diseased portion of the bone was excised and 
a permanent cure was effected. The lower jaw is very rarely 
affected by this disease, and the same may be said of the clav- 
icle, although the sterno-clavicular articulation may be the seat 
of tubercular suppuration. 



XXV. SURGICAL TUBERCULOSIS 
OF JOINTS. 

There are two forms of tuberculous disease of joints. In the 
more common (or osteopathic) form the disease begins in the 
epiphyseal ends of the bones, as has already been described. The 
nodule eventually softens down, and, instead of breaking externally 
and forming an abscess, it finds its way into the joint, either through 
a fistulous opening or by gradual involvement of the articular car- 
tilages. In the second variety, the arthropathia the synovial mem- 
brane is the seat of the disease. 

In the first form there exists a preliminary or prodromal stage 
of joint disease during which the bone only is affected. The 
nature of this process, having already been described, need not be 
repeated here. As the inflammatory process approaches the artic- 
ular cavity it not infrequently occurs that a reactive inflammation 
of an entirely non-specific character is set up within the joint. 
The joint becomes swollen and tender, and it is filled with a serous 
exudation which may last for some time, and finally disappear 
(hydrops tuberculosus); or the synovial membrane may become 
infected and granular without showing any evidence of tubercular 
infection ; or a fine layer of vascular tissue may grow out over the 
cartilage, closely resembling the pannus growth of the cornea. 
This tissue may involve the lining membrane of the joint, and it 
may lead to adhesions and cicatricial contractions to such an extent 
as to obliterate nearly the whole cavity of the joint. In such an 
extreme case the severe symptoms of tuberculous inflammation do 
not make their appearance in the joint, but the tuberculous disease 
remains confined to the bone. It is often the case with the knee- 
joint that when the tuberculous nodule which has formed in the 
bones finally breaks into the joint a greater portion of the inner 
cavity is shut off by adhesion; consequently the articular surface 
of but one of the condyles may become affected with the disease. 
Such an obliterating synovitis may occur in the hip-joint, the 
result of which is that the head of the bone becomes sometimes 
ankylosed to the acetabulum. Such changes are not unlike those 
adhesive inflammations seen so frequently in the pleura, the peri- 
toneum, and in other serous cavities, and they seem to protect the 

34 529 



530 SURGICAL PATHOLOGY AND THERAPEUTICS. 

joint, to a certain extent, from the tuberculous infection with 
which it is threatened. This kind of inflammatory reaction is 
more often seen in the knee than in the hip; consequently suppu- 
ration with caries of the articular surfaces is less likely to occur in 
the knee. 

If, however, tuberculous material finds its way into a perfectly 
healthy joint, it is readily spread about by the movements of the 
limb into all parts of the synovial capsule, which soon becomes 
infected: this is well shown by Cheyne's experiments upon ani- 
mals. Tuberculosis of the joint of a goat was produced by injec- 
tion of tuberculous sputa directly into the synovial cavity, and also 
by boring a hole into one of the bones of the joint and introducing 
the same virus into the cavity thus made. Emulsion of tubercu- 
lous pus in distilled water was also injected into a joint with the 
same result. The same emulsion injected into the femoral artery 
produced an infarction in the tibia. Pure cultures injected into 
the knee-joints of rabbits yielded typical results in eleven cases out 
of twelve. 

The infection of the joint from bone occurs by the gradual 
spread of the tuberculous process through the connective tissue of 
the Haversian canals, and by gradual absorption of the bony 
trabecular, until finally the tubercular material breaks into the 
joint by a free opening in the articular surface or by the forma- 
tion of granulation tissue, which gradually dissects off the articu- 
lar cartilage. In other cases the deposit may reach the surface at 
the margin of the synovial membrane, which becomes thickened 
and shuts off the deposit for a time from the joint-cavity. This 
thickened patch subsequently becomes infiltrated with tubercles. 
When an osseous growth of tubercle has broken into a joint we 
know the disease is at first confined to the synovial membrane, 
and the tubercular layer can easily be scraped off without sac- 
rificing the ligaments of the joint. Therefore, when the dis- 
ease has not spread from this point, all that may be necessary is 
to remove the original nodule or sequestrum and a margin of 
synovial membrane without resecting the joint. 

If the tuberculous nodule communicates freely with the cavity 
of the joint, the infection of synovial membrane rapidly takes 
place. The masses of miliary tubercles run together at the point 
first infected, and thence spread gradually over the synovial mem- 
brane, which soon becomes infiltrated with the diseased tissue. In 
some cases the membrane retains its continuity, the surface is moist 
and smooth, and is studded with tubercle, which, however, does 



SURGICAL TUBERCULOSIS OF JOINTS. 531 

not have a tendency to disorganize the membrane. When there is 
an exuberant growth of vascular tissue there may be an extensive 
formation of granulations, producing the so-called "fungous" type 
of joint disease. 

In still another form there is a tendency to the breaking down 
of the tubercular masses and to the formation of pus. This type 
is more frequently seen in elderly people, and the prognosis is usu- 
ally unfavorable. The membrane is readily perforated, and peri- 
articular abscesses are formed which may or may not communicate 
with the joint by a fistulous opening. As a result of the entrance 
of this large quantity of broken-down material into the joint the 
cartilage and the bones are generally left in a carious condition. 
Instead of pus there may occasionally be a turbid serum in the 
joint which may be slightly hemorrhagic. This tuberculous 
hydrops is, however, not very common. 

The bone type of joint disease is the commonest form of the two, 
and it is found chiefly in children, whereas the ordinary synovial 
tuberculosis is more frequently seen in adults. It seems somewhat 
to be a matter of chance whether the joint becomes infected with 
tubercle from the bone, or whether the broken-down products may 
not find their way to the surface without involving the joint. The 
cartilage is readily affected by the growth of granulation tissue 
into the joint, or by the presence of pus, owing to its feeble resist- 
ing power. The first change seen is the spread of a fibrous vas- 
cular tissue over the surface of the cartilage, the so-called ' ' pan- 
nus n growth, which becomes thinner and thinner in passing from 
the edge of the synovial membrane or from the opening of the 
tuberculous fistula. Subsequently the cartilage softens, loses its 
bluish-white color, and changes to a fibro-cartilage, and later to 
fibrous tissue, which finally becomes infiltrated with tubercle. 
When the tuberculous material breaks down the softened cartilage 
may be washed away, and the so-called ' ' ulceration of the cartilage ' ' 
is produced. 

At other times the growth of the tubercular granulations from 
the subjacent bone is so exuberant that the entire cartilage may be 
dissected off the head of the bone. This result is occasionally 
seen in the hip-joint, where the cartilage may be lifted off cap-like. 

In the primary synovial form of tubercular disease the tubercu- 
lous infiltration of the bone is usually comparatively superficial. 

A peculiar form of joint disease, described by Volkmann as 
caries sicca, occasionally attacks the shoulder-joint, but it may also 
be seen in other joints. It is characterized by a growth of scanty, 



532 SURGICAL PATHOLOGY AND THERAPEUTICS. 

tough, and feebly vascular granulations from the synovial mem- 
brane, which growth penetrates the cartilage and gradually eats 
into and destroys large portions of the head of the bone without 
the formation of pus. There is often considerable atrophy of the 
remaining portions of the head and neck of the bone. The usual 
external signs of tuberculous disease of the bone are of course 
wanting. It is most frequently seen between the age of puberty 
and thirty years. It runs its course slowly over a period of one or 
two years, and terminates in ankylosis of the joint. 

Volkmann also described large isolated tubercular nodules 
(sometimes the size of a pigeon's ^gg) which project as a pedicu- 
lated tumor into the joint. The fibrous nodule is composed of 
dense tissue which contains but few miliary tubercles, or, again, it 
may contain numbers of tubercles which show a tendency to break 
down. The adjacent synovial membrane is at first unaffected, but 
later it is infiltrated with tubercle. Volkmann recommends for 
these cases extirpation of the nodule with temporary drainage of 
the joint. A rare form of polypoid growth in the joint is that con- 
taining adipose tissue. It may grow to considerable size, and the 
surface is usually studded with tubercle, which appears to occur 
secondarily. 

In some cases of tuberculous joint disease, particularly those in 
which there is a sero-fibrinous effusion, rice-bodies are found in 
large numbers. They appear to consist of coagulated fibrin and 
of fatty degenerated cells. They are not always associated with 
tuberculosis, but it is found in certain cases that the synovial mem- 
brane is infiltrated with tubercle. In many cases when the rice- 
bodies are first removed no tubercular disease is found, but the dis- 
ease may appear later. Their presence in the joint, therefore, is a 
suspicious circumstance. The exudation of fibrin which occurs 
with the formation of tubercle seems to be connected in some way 
with their growth. As in the sheaths of tendons, they may, how- 
ever, be independent of tubercular disease. They are usually 
found in joints which have still retained their motion. They may 
sometimes be felt in the lateral folds of a joint, and their presence 
may also be recognized by a peculiar crackling sensation like that 
produced in compressing snow. 

The changes in the soft parts connected with the joints are very 
striking in this disease. The capsules and the surrounding con- 
nective tissue, and even certain structures within the joint itself, 
are transformed into a gelatinous mass. So characteristic is this 
appearance that it was given the name "gelatinous disease of the 



SURGICAL TUBERCULOSIS OF JOINTS. 



533 



joint'' by Brodie. Even the muscles and tendons appear to be 
subject to this peculiar change. In a case the writer remembers 
seeing the muscular tissue of the entire lower third of the thigh was 
affected. In some joints the tendons are so matted together by this 
condition of the tissues that motion of the joint is seriously impaired. 

According to Krause, this gelatinous change is not tuberculous in 
character, but it is due to a venous stasis resulting from the increase 
in the contents of the joint-capsule and the extra-capsular growth. 
As the result of the consequent oedema, the mucin, which normally 
exists in the tissue, is dissolved. A similar development of mucous 
tissue occurs, according to Koster, in the development of a 
myxoma. There is found, however, a similar growth of gelatin- 
ous material around and in the sheaths of infected tendons when 
no such obstruction to the circulation exists, and it seems prob- 
able, therefore, that the peculiar formation seen so rarely in 
other forms of disease, and so characteristic of tuberculosis 
of the joint, must be the result of chemical changes brought 
about directly by the presence of the bacilli in the surrounding 
tissues. 

The inflammatory reaction may 
extend from the original nodule to 
the periosteum, and it may produce 
an abundant growth of osteophytes 
which mark the limits of the cari- 
ous ulceration of the bone. This 
bony growth is analogous to the 
callous edges so often seen in 
chronic ulcerations of the skin in 
the lower extremities. (Fig. 81). 

Among the numerous patholog- 
ical changes brought about during 
the course of the disease are those 
due to pressure caused by the spas- 
modic contraction of the muscles. 
This contraction, which is due to 
reflex irritation of the nerves, fur- 
nishes one of the most marked clinical symptoms of the disease. 
In this way the ulceration of the cartilage is greatly increased, and 
even the carious bone is absorbed, and the spread of the tubercular 
process is favored by the pressure. By this muscular action not 
only great deformities of the spine are brought about, but joints 
are also dislocated and great deformity is produced. 




FIg. 81. — Tuberculosis of the End of the 
Humerus, showing caries of the articu- 
lar surface and osteophytes due to inflam- 
mation of the periosteum (Sp. 1399, War- 
ren Museum). 



534 SURGICAL PATHOLOGY AXD THERAPEUTICS. 

When the disease takes a favorable turn, cure may be brought 
about by the absorption of the tubercular tissue and its replace- 
ment by healthy granulation tissue. Cicatricial contraction occurs 
also in the inflamed periarticular tissues. This contraction brings 
about an impairment of motion which may amount to false anky- 
losis. In many cases where the anatomical structure of the joint 
is fairly well preserved there is a diminution in the area of the 
articular cavity by the formation of adhesions and the obliteration 
of some of the synovial pouches. When ossification of the cica- 
tricial tissue occurs, true ankylosis results. 

In the bones the tuberculous masses — even the sequestra — 
may be absorbed and be replaced by healthy bony tissue. Cheesy 
foci, however, mav remain for years unabsorbed without showing 
signs of their presence. These foci are often discovered during 
operations for correcting deformity. Such a condition shows the 
possibility of a recurrence of the disease long after the patient is 
supposed to have been cured. It should be said, however, that 
these nodules tend to remain local in the majority of cases, and 
that it is only after an unsuccessful surgical operation that general 
miliary tuberculosis is more likely to result. Disturbances in the 
normal growth of the bone may be produced by the irregular pres- 
sure which is often exerted in a diseased joint. In the so-called 
" dislocation of the knee-joint backward n the anterior portion of 
the condyles of the femur may develop more rapidly than the pos- 
terior portions. The reduction of such subluxations is prevented 
by the lateral ligaments, which are insufficiently long to permit 
the tibia being placed beneath the condyles. 

A rare occurrence is an actual elongation of the shaft of the 
bone, due to chronic inflammatory irritation. Atrophy of the bone 
is much commoner. The fatty tissue in the cancellated spaces of 
the bone is increased in quantity, the trabecular become thinner, 
and the amount of medullary tissue in the epiphyses and shaft is 
increased, while the cortical bone is much thinner than usual. 
Not only is there rarefying ostitis in the interior of the bone, but 
its dimensions mav also be diminished, the bone being shorter and 
thinner than its fellow. With the return of the natural physiolog- 
ical action the bone regains its normal strength and density, but it 
will probably never be quite so large as it would have been if 
atrophy had not occurred before it reached its full growth. If the 
epiphyseal line is prematurely destroyed, the growth of the bone 
will be arrested, and then the future use of the limb will seriously 
be impaired. 



SURGICAL TUBERCULOSIS OF JO/NTS. 535 

Some of the peculiarities of the disease in individual joints may 
now be studied. In the hip-joint, in the greater number of cases, the 
disease is found originally in the bone, but, according to Cheyne, it 
does not so extensively occur there as authors are disposed to think. 
At all events, a large number of cases are examples of primary 
disease of the synovial membrane. The tubercular deposits more 
frequently occur in the acetabulum than in the femur. In the 
latter case they are seen in the head as well as in the neck, and 
even in the trochanter. The farther they are removed from the 
joint the less likely are they to involve it. When this cavity 
becomes affected the disease spreads from the point of reflection 
of the synovial membrane and from the ligamentum teres over the 
cartilage. The granulations are filled with miliary tubercles, and 
they lie on the surface of the synovial membrane or they infiltrate 
its substance. The fluid in the joint is only slightly increased and 
altered; it is somewhat turbid and is streaked with pus or with blood. 
At times the fluid may be distinctly purulent. The ligamentum 
teres as the disease advances is attacked, and it becomes softened 
to a pulp. The bone becomes involved first at the edge of the fold 
of the synovial membrane. The tubercles multiply in the super- 
ficial layers of the bone, and they dissect off the cartilage at several 
points, giving the latter a sieve-like appearance. The same process 
goes on in the acetabulum, and in well-marked cases of the dis- 
ease the femoral and acetabular cartilages may lie completely sepa- 
rated between the ends of the bones. Before separation, the cartilage 
may already have ulcerated in several places, particularly where the 
head of the bone and the acetabulum press against each other: the 
effect of this pressure is to increase the amount of ulceration of the 
bone, and consequently the acetabulum may become enlarged bv 
caries at this portion of its circumference. In the mean time the 
capsule of the joint is perforated and periarticular abscesses are 
formed. These abscesses may develop without perforation of the 
joint, but such abscesses are comparatively rare. In later stages 
of the disease the tubercular process, after destroying the liga- 
mentum teres, attacks its point of insertion in the acetabulum, 
and, the bone being gradually eaten away, an accumulation of 
pus may form within the pelvis. This complication, however, 
is infrequent. The pus in different cases varies greatly in amount, 
but in the primary synovial form of the disease it is always certain 
to be found. 

In caries sicca pus is not formed, but this type of the disease 
rarely attacks the hip-joint. 



53 6 SURGICAL PATHOLOGY AND THERAPEUTICS. 

In the later stages of the disease the joint looks about the same 
whether it was originally attacked by the synovial or the osseous 
form of the disease. At this time absorption of the bone has taken 
place. The head of the femur is partly destroyed by caries, and its 
bony structure is so softened by rarefying ostitis that when pressed 
against the acetabulum more or less absorption of the bone occurs. 
This process is described by Volkmann as "ulcerating decubitus." 
There is also, from the same cause, an enlargement in the diameter 
of the acetabulum, due to pressure of the head of the femur after 
the protecting cartilage has been destroyed. As this pressure occurs 
with the limb in a state of adduction and flexion, the enlargement 
of the cavity takes place chiefly in the posterior and upper margins 
of the acetabulum. This condition is known as the wandering 
acetabulum. As the head of the femur is also greatly atrophied, 
its displacement from the original portion is therefore considerable, 
and the resemblance to a dislocation is consequently very close. 
This displacement in many cases is a cause of shortening of the 
limb. In other cases the capsule and the ligaments, owing to the 
distention of the joint by fluid and to the relaxation of the liga- 
ments, are unable to withstand the action of the muscles, and the 
head of the bone is forced completely out of the socket, or it rests 
upon the edge of the socket so that a deep groove is worn in its 
articular surface. The displacements occur very gradually; the 
relaxed ligaments permit motion in various directions; the joint 
"wabbles," and a slight accident may therefore result in a sud- 
den dislocation of the bone. 

The amount of destruction of bone tissue is sometimes enor- 
mous. The head and neck, and even a portion of the shaft, of the 
femur may be destroyed. In such cases the shortening and dis- 
placement of the limb are so great as seriously to impair its use- 
fulness. After the disease has once fully developed there is little 
probability of a cure without ankylosis, as the structures of the 
joint have been destroyed before the tubercular virus has been 
thoroughly eliminated by suppuration. In some of these cases 
tubercular nodules may remain unabsorbed after the disease is 
supposed to have been cured. Bradford reports tetanus occurring 
in a case of cured hip disease, and at the autopsy there was found 
a large tubercular focus, which was the only source to which the 
tetanus could be assigned. 

In the knee-joint at the period of life when the disease is most 
common — namely, in childhood — the origin of the disease is as 
frequent in the bone as in the synovial membrane: as age advances 



SURGICAL TUBERCULOSIS OF JOINTS. 537 

the bony form is more common, and the frequency of sequestra in 
old people makes the disease more obstinate (Cheyne). In old peo- 
ple wedge-shaped sequestra are often seen after injuries. When 
tubercular nodules are found in the bones the internal condyle of 
the femur is the point most frequently attacked, but these nodules 
are often found also in the epiphysis of the tibia. 

Tumor albiis, or white swelling — which term is applied chiefly 
to disease in the knee-joint — is due to the formation of granulation 
tissue in the joint, to the gelatinous change in the tissue about the 
joint, and to the enlargement of the ends of the bone. The 
simultaneous atrophy of the muscles of the limb serves to make 
the swelling more prominent. The whiteness of the skin is due 
to the absence of all inflammation in the integuments in the early 
stages of the disease. The development of tumor albus is ascribed 
by Roser to the frequent use of the knee-joint by a patient who has 
not yet received treatment. He thinks the thickening of the para- 
articular tissue is due to the irritation brought about by frequent 
motion. The minute tuberculous changes which occur in the joint 
have already been sufficiently described. In no joint can the spread 
of the tubercular tissue and its destructive effect upon the cartilages 
be better observed than in the knee. Occasionally the amount of 
pus formed is considerable, and, as it may not perforate the capsule, 
it distends the joint, giving a sense of fluctuation like that of 
hydrops. This condition has been called "cold abscess of the 
joint." It is not, however, a frequent complication. On opening 
a joint in well-advanced stages of the disease there is found more 
disease than might be supposed to exist from the clinical symp- 
toms. The ulceration of the cartilages is well advanced and the 
synovial membrane is infiltrated with tubercle. Several periartic- 
ular abscesses are usually disclosed by the incision, and they may 
or may not communicate with the joint. It is rare to find a case 
where there is not considerable disease also of the bone. 

In the early stage of the disease there is flexion of the knee- 
joint from muscular contraction. This flexion brings the head of 
the tibia in contact with the posterior aspect of the condyles of the 
femur. The pressure of the bones favors ulcerative decubitus of 
the cartilage and bone at these points. As the result of the absorp- 
tion of the bone, which is thus brought about, the head of the tibia 
slips backward over the femur. This displacement is of course 
favored by the relaxation of the diseased capsule: it is not caused 
wholly by muscular contraction, but is due in part to the cicatri- 
cial contraction of the diseased and atrophied tissues behind the 



53$ SURGICAL PATHOLOGY AND THERAPEUTICS, 

joint. In addition to flexion there is also a certain amount of 
external rotation of the leg upon the thigh, which rotation appears 
to be produced by the position of the contracted limb upon the bed. 

The shoulder-joint is not a very frequent seat of tuberculosis ; 
when the latter does occur, it is found chiefly in adult life. Pri- 
mary synovial disease of the shoulder-joint is rare. In fungous 
tuberculosis of the joint with suppuration there is generally found 
a primary deposit in the end of the humerus. The greater tuberos- 
ity is the most frequent seat of such a nodule, but the head of the 
bone may also be affected. Disease of the neck of the scapula is 
uncommon. 

The wedge-shaped infarction is a type of the disease not infre- 
quently found in the head of the humerus. These nodules may 
remain some time without causing suppuration. 

Krause reports a case of a man, forty years of age, who suffered from 
rheumatic pains in the left shoulder. The pain had been so severe that he 
had been unable for three months to use his shoulder, in the external appear- 
ance of which there was little change be3*ond a slight emaciation. There 
was, however, marked pain on pressure over the lesser tuberosity. An 
exploratory incision disclosed a large tuberculous nodule in the head of the 
bone, which was accordingly resected. 

As the disease progresses the localized pain becomes more marked 
and the patient instinctively holds the arm at rest; the contour of 
the joint becomes enlarged, and the natural depressions in front 
and behind the joint disappear. Large cold abscesses may accom- 
pany the disease in its later stages. They follow the route of the 
intermuscular spaces. 

The most interesting form of disease of the shoulder-joint is 
caries sicca, which has already been described. The small amount 
of granulation tissue which develops at any one time and the 
chronic course of the infection are peculiarities that cause the dis- 
ease to pass unrecognized. There is great atrophy of the muscular 
surroundings of the joint, and the head of the bone gradually sinks 
away and disappears. There is no suppurative inflammation, and, 
in fact, no sign of inflammatory change. The shoulder is stiff and 
the arm is held close to the side. The pain is usually severe and 
radiates down the arm, it being often mistaken for rheumatism. 
The deltoid prominence disappears and the coracoid process be- 
comes unusually prominent, the condition sometimes closely resem- 
bling a dislocation. The writer has seen several of these cases, 
mostly in young children, and they usually terminate in bony 
ankylosis. 



SI r RGR \ 1 1. Tl r BERC '( 7. ( )S/S ( >F J( )INTS. 539 

Tuberculosis of the elbow-joint may occur spontaneously or as 
the result of slight injuries, particularly in children. According 
to Billroth's statistics, of 1996 cases of caries of the boues, there 
were 93 cases of disease of the elbow and 239 cases of disease of 
the knee-joint; in 198 cases the hip, in 150 cases the ankle, in 41 
cases the wrist, and in 28 cases the shoulder, were affected. Accord- 
ing to Billroth, disease of the elbow holds the fourth place in point 
of frequency. 

The disease more frequently begins in the bone, a favorite spot 
being the spongy tissue of the olecranon. Volkmann describes 
such a case where pus was discharged both into the joint and 
externally. The removal of the sequestrum, with thorough curet- 
ting of the bone, was followed by a restoration of the functions 
of the joint. Nodules may also develop in the epiphysis of the 
humerus, but they rarely occur in the radius. In certain cases the 
synovial membrane may first be affected, and the bones will be 
attacked when the disease spreads to the point of insertion of the 
membrane in the articular ends of the bone. Suppuration is usu- 
ally slight. When the bones are affected the presence of the nodule 
will be indicated by localized pain and by some enlargement of the 
bone. If the synovial membrane is first attacked, an elastic swelling 
usually shows itself between the head of the radius and the olecra- 
non. The movements of the joint are impaired early, as indicated 
by inability to extend fully the arm. 

As the joint gradually becomes disorganized the surrounding 
tissues are swollen, and they undergo the characteristic gelatinous 
changes, and in extreme cases there is a well-marked tumor albus 
with the spindle-shaped swelling. As pus forms numerous sinuses 
open, and the tuberculosis may eventually extend even to the skin. 
In old persons and in those who have been treated unsuccessfully 
by some operative procedure the disease of the soft parts may be- 
come very extensive, necessitating amputation. 

The prognosis in tubercular disease of the elbow is not favorable 
for the re-establishment of motion unless the affection is treated at 
a very early stage. This joint is so complicated that the disease 
involves a large and a comparatively widespread surface of synovial 
membrane before its presence is discovered (Bradford). 

In studying the clinical symptoms the point of origin in the 
bones must be sought for chiefly in the early stages of the disease. 
The period during which the morbid process remains confined to 
the bone is often a long one. In some rare cases several years may 
elapse before the disease advances beyond this stage. It will read- 



54-0 SURGICAL PATHOLOGY AND THERAPEUTICS. 

ily be seen that the beginning of the affection is very gradual and 
insidious. The patient experiences an inability to use the joint, 
and there is some slight stiffness. If one of the joints of the lower 
extremity is affected, there will be slight lameness. If it is a super- 
ficial joint, such as the knee- or the elbow-joint, there may be slight 
swelling of some portion of the bone, pressure upon which gives 
rise to pain. As these nodules enlarge pus may form and a frag- 
ment of the bone with pus may be discharged. The adjacent joint 
may at this time suffer from non-tubercular synovitis due to its 
proximity to the tubercular inflammation. As the result of such 
changes there is an enlargement of the joint. The anatomical 
outlines disappear and the joint may assume a more or less spindle 
shape. The veins are more or less injected, and the skin becomes 
somewhat thin and shiny like the top of a bald head (Krause). The 
enlargement of the joint is emphasized by atrophy of the muscle. 
In tumor albus of the knee the muscles of the thieh and the calf 
are affected in this way. The adipose tissue is largely absorbed, 
and even the skin in some cases seems thinner than normal. Meas- 
urements of the limb will show a diminution in its circumference 
at an early stage. In the later stages of the disease the muscle 
may undergo degeneration and absorption of the contractile sub- 
stance. 

Muscular fixation is a symptom of nearly all forms of tubercular 
joint disease. The joint is usually flexed or adducted, and is more 
or less rigidly held in that position. This abnormal position of the 
joint has been attributed to distention with fluids, it being supposed 
that the flexed position gives the most room for fluid; but the flex- 
ion is undoubtedly due to muscular spasm from reflex irritation. 
In hip disease spasm is one of the earliest symptoms, and it has 
been said that there can be no disease present if there is no limita- 
tion in the motion of the joint. When the joint is more or less 
disorganized this contraction of the muscles may lead, as has been 
seen, to subluxation. 

Pain is a prominent symptom of joint disease, although occa- 
sionally it may entirely be wanting. Reference has already been 
made to rheumatic pains accompanying caries sicca in the shoulder- 
joint, there being frequently a painful point anterior and external 
to the coracoid process. In hip disease the pain is almost invariably 
situated in the knee, and there is great sensitiveness to jarring of 
the limb. There is an unconscious protection of the joint in the 
movements of the patient. The reference of pain to the knee is 
attributed by Bradford and others to the intimate relations and an- 



SURGICAL TUBERCULOSIS OF JO/NTS. 541 

astomoses of the sciatic, obturator, and anterior crural nerves. 
According to Sayre, the pain is the result of the struggle between 
the adductor muscles and the distended capsule. The so-called 
41 night-cries " which occur in the early stages of hip disease, 
and more rarely in knee-joint disease, are described by patients 
as caused by an extremely sharp and severe pain suddenly inter- 
rupting sleep, and leaving an ill-defined sense of aching in the 
thigh and hip as if the hip had sustained a blow. 

The next important point of tenderness on pressure lies in 
the groin just external to the femoral vessels. Tenderness is 
detected in the knee on the inner surface of the head of the tibia. 
Pain is not, however, severe in the knee except in acute exacerba- 
tions. The anterior and lateral portions of the ankle-joint are the 
tenderest spots. Pain on pressure is felt at the elbow-joint over 
the head of the radius and the neighboring part of the capsule. 
Pain in Pott's disease is generally referred to the back of the 
head, the shoulders, the chest, and the abdomen. In the latter 
case the child usually complains of " stomach-ache." Tenderness 
on pressure over the spine is not a symptom of this disease. 

Heat is a symptom that can be relied upon in certain stages of 
disease or in certain joints. In the knee when the disease is well 
developed heat is usually present, especially if any exacerbation 
takes place. 

There is usually little if any febrile disturbance during the early 
stages of the disease and while it is confined to the bone or joint. 
Even when a cold abscess is present the rise of temperature is only 
slight, varying from 1 to 2° F. Fever may occur, however, if pul- 
monary tuberculosis supervenes or if there is tuberculosis of the 
intestinal canal or basilar meningitis. In cases of miliary tubercu- 
losis there may be considerable fever, and it may be of the con- 
tinued type. There is great exacerbation of both local and consti- 
tutional symptoms when a cold abscess breaks. The joint swells, 
the skin is reddened, and the discharge assumes the character of a 
phlegmonous suppuration. There is high fever, and generally 
there is increased emaciation. These changes are due to a mixed 
infection with pyogenic cocci. Eventually this fever is of the hectic 
type, consisting of an evening rise of temperature, with a return to 
the normal in the morning. Pronounced anaemia is regarded by 
some as an unfavorable symptom in different forms of tuberculosis, 
as it is an indication that generalization of the tuberculous virus 
has taken place. 

Cure may take place spontaneously even in most aggravated 



542 SURGICAL PATHOLOGY AND THERAPEUTICS. 

cases, but generally with ankylosis or deformity. Even abscesses 
of considerable size may be absorbed. 

A fair amount of motion often remains in some joints after 
recovery, a portion only of the joint having been destroyed by the 
disease. It is not uncommon for relapses to occur several years 
after apparent cure has taken place, the new infection being derived 
from the cheesy material remaining imprisoned in the cicatricial 
tissue. In unfavorable cases there is apt to be found albuminuria, 
which is usually caused by the presence of amyloid degeneration 
of the kidneys. These changes are probably brought about by 
chemical substances which are taken up into the lymphatic sys- 
tem, and occasionally the lymphatic glands are seen thus affected. 
Although the statement is made that such degeneration perma- 
nently destroys the function of tissues or the organs thus affected, 
it is possible that after cure of the joint has taken place the 
amyloid degeneration may disappear. In a case of tuberculosis of 
the neck and trochanter of the femur of several years' duration, 
followed by purulent synovitis of the knee-joint, there was evi- 
dence of an amyloid degeneration of the kidneys and spleen and 
some enlargement of the liver, the signs of which degeneration 
disappeared after a successful amputation of the hip-joint. Pulmo- 
nary tuberculosis may occur as a complication, particularly in con- 
nection with caries of the carpus. Children are more likely to be 
affected with miliary tuberculosis in unfavorable cases, especially 
after operations have been performed. 

From what has been said about the pathology of tuberculosis 
of bones and joints it will be gathered that all the affections 
hitherto known as caries of the joints, scrofulous disease, gelatin- 
ous disease, fungous or strumous affections, spina ventosa, etc. are, 
almost without exception, forms of tuberculosis. As the cachectic 
condition marked by anaemia, emaciation, and hectic fever does 
not develop until the later stages of the disease, the student must 
not be led into supposing that a good general condition of the 
patient precludes the diagnosis of tubercular disease; for a nodule 
may remain for a long time concealed in the cancellated tissue of 
the bone without producing any constitutional disturbance what- 
ever. There are a number of other forms of infectious bone dis- 
ease, which, however, begin, as a rule, as acute infections, and 
which subsequently become chronic. The most frequent of these 
infections is acute osteomyelitis, which may often lead to suppura- 
tion of the joint and to destruction of the articular cartilage. This 
affection begins as a very acute inflammation of the bone, and fre- 



SURGICAL TUBERCULOSIS OF JOINTS. 543 

quently with profound constitutional disturbance. After necrosis 
has taken place and the abscess has broken and fistulous openings 
have formed, the acute stage passes away and the patient is left with 
chronic suppuration of the bone. This condition is, however, read- 
ily distinguished from tuberculosis, as the inflammation involves 
the shaft of the bone instead of the epiphysis. The previous his- 
tory of the case and the presence in the shaft of a large sequestrum 
which has the shape of the original bone will enable one to make 
the diagnosis of osteomyelitis in most cases. The appearance of 
the fistulous openings will also be a guide, for in this form of bone 
disease the tubercular granulations are absent. In those rarer forms 
of osteomyelitis found in the epiphyses of the bones the difficulty 
of diagnosis is greater. An effort should be made in such cases to 
demonstrate the presence of tubercle bacilli, although their absence 
will not definitely settle the point, as they are difficult to find even 
in well-marked types of osseous tuberculosis. The tubercular 
sequestra are, as a rule, smaller and more irregular and are filled 
with cheesy material. Many forms of syphilis of the bones are not 
readily distinguished from tuberculous disease. There is not the 
same tendency to suppuration in syphilis, and the disease usually 
affects certain localities. Syphilitic caries of the bones of the cra- 
nium is usually very extensive, and it often runs its course without 
suppuration. It is so typical a form of the disease that when once 
seen it is not likely to be mistaken for anything else. There is 
sometimes a tendency to the formation of sequestra. The writer 
has seen extensive disease of this kind in the frontal bone, but in 
such cases the history points so distinctly to a syphilitic origin 
that a mistake in diagnosis is not likely to be made. When sup- 
puration does take place the pyogenic membrane is tough, and it 
cannot be scraped off the subjacent tissue, whereas in tuberculosis 
the membrane is removed with great ease. A syphilitic gumma 
may sometimes form in the capsule, and may closely resemble an 
isolated tubercular nodule. These cases will of course yield to 
treatment with iodide of potassium. 

Metastatic inflammations of the joints occasionally occur as 
complications of acute exanthemata, a portion of which inflam- 
mations are the result of septic or pysemic infection, and a cer- 
tain number of them are cases of tuberculous infection which has 
developed during the favorable conditions offered by the diseased 
state of the system. Volkmann suggests that some of them may- 
be due to the action of the virus of the exanthema. 

Serous effusion into the knee-joint, hydrops articnli, or " water 



544 SURGICAL PATHOLOGY AND THERAPEUTICS. 

on the knee," occasionally assumes a type which may suggest the 
possibility of tuberculosis. There is, in such cases, a so-called 
"arthritic atrophy" of the muscles, with impairment of the 
nutrition of the limb that is suggestive of organic disease. A 
careful examination, however, will clearly show the true state 
of affairs. The "fluctuation" of the patella, the absence of 
pain on pressure or of grating of the joint or of any infiltration 
of the soft parts, are sufficiently characteristic symptoms of this 
affection. Neuralgic or hysterical joints often disable persons who 
have sustained a slight injury, and they cause much anxiety. An 
examination in these cases shows an absence of all pathological 
changes. The shifting character of the pain and the presence of 
nervous or hysterical symptoms will aid in the diagnosis. Such 
symptoms yield readily to massage. 

Arthritis deformans occurs chiefly in elderly people. The cha- 
racteristic changes in the bone are so pronounced that a mistake in 
diagnosis is not likely to be made. The changes in the soft parts 
are much less marked than in tuberculosis. 

Periosteal sarcoma may sometimes be mistaken for tubercular 
disease. The writer has opened a supposed tuberculous knee-joint 
to find sarcoma of the femur. Myeloid sarcomata are usually found 
in well-recognized spots, such as the head of the tibia, or more 
rarely in the condyles of the femur and in the carpal extremity of 
the radius. 

In the advanced stage of tuberculosis the disorganization of the 
cartilages or the capsule enables one to obtain crepitus by free 
lateral rubbing of the articular surfaces against one another. 
Even when crepitus cannot be obtained the abnormal mobility 
of the joint is a suggestive symptom. 

The prognosis of these diseases is far more favorable in children 
than in adults, and in estimating the value of any special mode of 
treatment it is important to bear this fact in mind. It should not 
be forgotten also that the severest types of bone-and-joint disease 
may heal spontaneously, as the conditions for limiting and subse- 
quently for absorbing the tuberculous foci are more favorable in 
bone than in the internal organs; as, for instance, the lungs. In 
the former case the disease is shut in at first by a dense wall of 
bone or by the tough envelope of a joint capsule; in the latter case 
the infective products of the disease spread over the mucous mem- 
branes for a long distance before they are expelled, and in this way 
the disease is readily generalized. This localization is more marked 
in children. A diffuse suppuration of the carpus or of the tarsus 



SURGICAL TUBERCULOSIS OF JOINTS. 545 

is rare at this period of life, and a minor operation usually suffices 
for the cure of the affection. Caries of the wrist in adults is almost 
always followed by pulmonary tuberculosis. Resection of the ankle- 
joint for the disease in adult life is generally considered a useless 
operation, and amputation is practically the only resource in tuber- 
culosis of the carpus and tarsus at this age. 

The statistics of this disease do not show a very large percent- 
age of cures. Billroth estimates the mortality of cases observed 
by him during a period of sixteen years to be 27 per cent. ; Koenig 
records a mortality of 16 per cent, in 177 operations extending over 
a period of four years. Even if a local tuberculosis is successfully 
removed, it does not prevent the possibility of a later infection of 
the lungs or other organs, as the susceptibility of the individual 
still exists. It will remove, however, the danger of miliary tuber- 
culosis starting from this point. A local return shows that the 
operation has not thoroughly been performed. 

It is important to remember that even when the original focus 
has been removed the secondary abscesses and sinuses, if allowed 
to remain, are equally a great source of danger. In adults these 
secondary complications are even more dangerous than the original 
affection. 

The difference in the prognosis in the diseases of different joints 
is very great. The destructive processes which proceed in the hip- 
joint are more extensive and are more likely to be followed by sup- 
puration than those that take place in the knee, where a tendency 
to cicatrization often sets in early. In the most favorable cases it 
is unsafe to promise a cure in less than two or three years, and it 
should be borne in mind that there is always danger of a relapse 
even after several years of health. 

The constitutional treatment of tuberculous disease of the bones 
and joints differs little from that employed for other forms of tuber- 
culous disease. The great majority of the patients afflicted with 
this form of tuberculosis are unable to avail themselves fully of 
one important feature of the treatment, which consists in the 
selection of a suitable climate or of suitable surroundings. In 
European countries great importance is attached to a sea climate, 
many of the largest cities being situated in the interior of the 
continent. The important point to be obtained in most cases is 
a liberal supply of healthful air. A country life is therefore, as 
a rule, most favorable for a tuberculous patient, particularly a 
child, if the patient is not thereby deprived of too many home 
comforts. A liberal supply of fresh milk and eggs is one of the 
35 



54 6 SURGICAL PATHOLOGY AND THERAPEUTICS. 

principal points to be insisted upon in the diet. Among drugs 
cod-liver oil takes the first rank; the refined preparations of to- 
day have deprived this drug of many of its obnoxious qualities. 
It is well to advise the pure oil, to be obtained from as reliable 
a source as possible, and to enjoin the greatest care and cleanli- 
ness in the preservation of the bottle and cork and of every arti- 
cle used in its administration. In this way it may be adminis- 
tered in moderate doses for a long time without disturbing the 
digestion: one to two drachms for a child and three for an adult 
are usually sufficiently large doses. Preparations of phosphate 
of lime are supposed to favor bone-repair. Whether this sup- 
position be true or not, they serve as exceedingly valuable tonics 
in this disease. The syrup of the lactophosphate of lime may 
be administered in teaspoonful doses to children, and it is a 
preparation which they all like. The compound syrup of the 
hypophosphites, containing potassium, sodium, iron, manganese, 
quinine, and nux vomica, is equally useful for adults: it may 
also be given in drachm doses. Preparations of iron are indi- 
cated when in the more advanced stages anaemia begins to make 
its appearance, the syrup of the iodide of iron being considered 
one of the best. When amyloid degeneration of the kidneys and 
albuminuria make their appearance the administration of iodide 
of potassium internally is said to be of great benefit, the amount 
of albumin diminishing markedly during the use of the drug 
(Krause). 

One of the earliest forms of local treatment to be applied to a 
joint is fixation, which should be employed during the acute stage 
when the tubercular process is exciting surrounding inflammatory 
reaction. In this way inflammation is not aggravated, and many 
of its symptoms, such as pain and swelling, are immediately 
relieved. This alleviation can be accomplished in most joints by 
the use of the stiff bandage, which also possesses the great advan- 
tage of exerting gentle and continuous compression. Compression 
is a most effective agent in producing absorption, and it is particu- 
larly valuable during the granulating stage of the disease and 
before suppuration is established. The use of the stiff bandage on 
the knee-joint may sometimes be continued through a series of 
years with the most satisfactory results. At first a thin layer of 
plaster of Paris may be used, with a coating of silicate of potash or 
of dextrin. But later in the treatment a light dextrin or a silicate 
bandage may be applied and be renewed two or three times a year, 
and in this way the compression can be kept up over a long period 



SURGICAL TUBERCULOSIS OF JOINTS. 547 

of time. This treatment is more applicable to the knee than any 
other joint, but it is employed also in disease of the hip, the ankle, 
and the wrist, and more rarely in disease in the elbow; in the 
shonlder-joint it can be of little use. The advantages of the plas- 
ter jacket in Pott's disease are great, and its cheapness makes it a 
useful substitute for apparatus when expense is a matter to be 
considered. 

Another important element in the treatment of joint disease is 
extension, which is employed to overcome the spasmodic action of 
the muscles by which the pressure of the inflamed bones upon one 
another is increased. This increase of pressure not only favors the 
spread of the tuberculous disease, but produces in many cases also, 
as has already been seen, an absorption of the bone (ulcerative de- 
cubitus), which adds greatly to the deformity. Extension at one 
time was supposed to separate the diseased bones, but experiment 
has shown that the actual separation that occurs is but slight and 
under conditions which do not exist clinically. This mode of 
treatment is more applicable to the hip and knee than to any other 
joints, and it prevents or corrects flexion or abduction or subluxa- 
tion, besides relieving many of the symptoms of inflammation. 
Those forms of extension apparatus which oblige the patient to lie 
in bed are suitable only when the symptoms partake of an acute 
type, but for the more chronic forms the traction splints, such as 
have been devised by Sayre and Taylor, are to be preferred, as they 
permit locomotion. In the later stages of the disease, particularly 
of the hip and knee, traction may be replaced by protection. 
Protection is obtained by the use of crutches and by a high sole 
on the opposite foot, so that the diseased limb may swing clear of 
the ground during locomotion, or by means of the so-called " peri- 
neal crutch," an apparatus which may be worn beneath the cloth- 
ing for the support of the limb. The support should be continued 
for a considerable space of time after all active symptoms have dis- 
appeared. 

The malposition occurring in the knee-joint must be overcome 
by extension or by forcible reduction by flexion. If the joint does 
not yield to extension by weight-and-pulley in bed, the patient 
should be etherized and sufficient force be exerted to straighten the 
limb. Occasionally there will have been so much muscular con- 
traction that many of the tendons near the popliteal space must be 
divided before the limb can be straightened. After straightening 
has been accomplished it is advisable to keep the limb in a stiff 
bandage or in some form of apparatus to prevent a return of the 



54 8 SURGICAL PATHOLOGY AND THERAPEUTICS. 

deformity. Bony ankylosis in an unfavorable position can be 
relieved only by osteotomy. Malposition from ankylosis occurs 
occasionally in hip disease, but an excellent result may be ob- 
tained by cutting the femur just below the trochanters or through 
the neck, thus making it possible to straighten the limb. 

In the knee-joint the patella is occasionally ankylosed to the 
femur. If the patella offers an obstacle to the correction of a 
deformity, it may be separated from its attachment to the bone by 
the chisel. 

The treatment of cold abscess has varied greatly during recent 
years. When the antiseptic treatment was introduced, some of its 
most beneficial effects were supposed to be illustrated in the treat- 
ment of this affection. iVlthough septic infection with pyogenic 
bacteria was thus prevented, no effect was produced on the tuber- 
cular process, and the abscess was simply converted into a tubercu- 
lar sinus. A great step in advance was made when the tubercular 
nature of the pyogenic membrane was recognized. The method 
was then adopted of scraping away the membrane after laying open 
the abscess by a free incision. But the difficulty remained of not 
always being able to reach all the folds of the abscess-cavity, and 
small sinuses leading to concealed foci of disease were often over- 
looked; consequently the source of the whole trouble would remain 
untreated. The healing properties of iodoform in the treatment 
of tubercle having long been recognized, a method was finally 
devised whereby this drug could be brought in contact with all the 
ramifications of such a pus-cavity. Among the first to introduce 
this method were Billroth and Mikulicz. The following is Krause's 
description of the method: 

The abscess is first tapped under antiseptic precautions. It is 
best to use a good-sized trocar, so that clots of cheesy material and 
fragments of abscess-membrane can be removed readily through it. 
The cavity is then thoroughly irrigated with a 3 per cent, solution 
of boracic acid, and the iodoform preparation is injected. Solu- 
tions of iodoform in ether or in alcohol are more readily absorbed, 
but they may cause poisoning, and they have the disadvantage of 
leaving but a small quantity of the iodoform in the cavity. Krause 
objects also to iodoform oil on the same grounds. He uses a 10 per 
cent, solution — or, rather, suspension — of iodoform in glycerin. 
Another preparation is a 10 per cent, suspension of iodoform in 
water with 20 per cent, glycerin, 5 per cent, gum-arabic, and 1 per 
cent, carbolic acid. The finely-powdered iodoform is rubbed up 
with a few drops of glycerin, and is gradually added to the mix- 



SURGICAL TUBERCULOSIS OF JOINTS. 549 

ture, which must be well shaken before using. When properly 
prepared it can easily be injected with a hypodermic needle. As 
this drug is only in suspension, it is not absorbed, and it remains 
in contact with the pyogenic membrane. A gradual absorption 
does of course take place, but not with sufficient rapidity to cause 
poisoning. It is well to act with caution in cachectic subjects. 
For adults about 3 ounces of such a mixture may be introduced. 
Smaller doses are, however, more frequently used. The abscess- 
walls should be so manipulated as to bring the mixture in contact 
with all the folds of the membrane. It is not usually necessary to 
put a stitch in the puncture wound, a light dressing being all that 
is needed. If the trocar is plugged with cheesy clots, an incision 
may be necessary, which must of course be sewed up before the 
injection is made. 

After the first injection the swelling subsides, and in some cases 
it disappears entirely in a few weeks. Two or three injections are, 
however, usually necessary at intervals of a few weeks. If the 
abscess refills, it must be washed out again with boracic acid. In 
this case several months may elapse before a cure is effected. At 
the second puncture the discharge through the canula is of a more 
mucous character and of a darker color, and it is mixed with par- 
ticles of iodoform powder. Later the fluid becomes clear and ropy, 
containing under the microscope round cells in a state of fatty 
degeneration. Occasionally a fistula forms which discharges a sim- 
ilar fluid, sometimes in considerable quantity, but the healing pro- 
cess does not appear to be disturbed. 

Iodoform appears to cause a breaking down of the tuberculous 
tissue, which is then thrown off. If fragments of the wall of such 
abscesses are examined microscopically from time to time, it will 
be found that the bacilli have disappeared soon after the beginning 
of the treatment. The tubercles are seen infiltrated with round 
cells and serous exudation, and many of the cells of the tubercle 
are in a state of fatty degeneration. The subjacent fibrous layer 
throws out granulations which destroy and throw off the tubercu- 
lar membrane. When all the broken-down material has disap- 
peared the granulations cicatrize and the abscess heals. 

In tuberculous joints the same treatment may be carried out. If 
there is pus in the joint, the treatment is the same as for abscess, a 
smaller quantity of the mixture being used: about an ounce is suf- 
ficient. A trocar about 2 mm. in diameter is better than a hypo- 
dermic needle. Passive motion may be employed to spread the mix- 
ture through the joint. It has no bad effect upon healthy cartilage. 



55° SURGICAL PATHOLOGY AND THERAPEUTICS. 

In the wrist the best point to select for puncture is just below 
the styloid process of the radius and ulna. In the elbow-joint the 
head of the radius is considered the most available spot. In the 
shoulder-joint the trocar may be introduced externally to the cora- 
coid process, just outside the spot where the spine of the scapula 
becomes continuous with the acromion. In injecting the hip-joint 
along trocar should be used; the limb should be extended, slightly 
adducted, and rotated inwardly. The instrument, which is inserted 
just above the trochanter major, should be pushed until it comes in 
contact with the head of the bone. In tapping the knee-joint care 
must be taken to insert the instrument beneath the patella. In the 
ankle-joint the point to enter is under the tip of either malleolus. 
Anaesthesia is usually unnecessary, but a i or a 2 per cent, solution 
of cocaine may be used for the skin. A slight rise of temperature 
occurs for one or two days after the injection, but it is of no patho- 
logical significance. Three injections performed at intervals of 
about four weeks are usually necessary. There is considerable 
relief of pain after the first injection, but the swelling does not 
subside with rapidity. The tissues become, however, somewhat 
firmer in favorable cases. If there is pus in the joint, it generally 
returns after the first injection, but after the third or fourth injec- 
tion it disappears. The restoration of motion to the joint will 
depend upon the amount of change which has already taken place, 
but cases of complete return of the normal movements are reported. 

This mode of treatment appears best suited to young people and 
children, though adult life does not constitute a contraindication. 
The treatment is well adapted to tuberculous wrists, even when 
pulmonary disease is present. The method should be tried even 
in severe cases before resorting to operation. It may be tried in 
cases of primary epiphyseal disease as well as in tuberculosis of 
the synovial membrane. It should always be employed in cases 
of suppurating bone disease so situated that the bone cannot easily 
be reached by the operator. If, however, the bone can readily be 
reached through the abscess, an operation is to be preferred, for in 
this way the surgeon is in a position to leave the parts in a condi- 
tion favorable for permanent cure. Balsam of Peru has largely 
been used in the same way, but not with such brilliant results. 

Billroth lately adopted a combination of the old method of 
scraping an abscess and the iodoform-glycerin treatment. The 
abscess is first laid open by a long incision, and the lining mem- 
brane is thoroughly scrubbed off with iodoform gauze or some 
similar material, and, after the bleeding has been stopped, 



SURGICAL TUBERCULOSIS OF JO /NTS. 551 

fistulous openings are sought for and traced to their source, coun- 
ter-openings being made, if necessary, for the purpose. The pri- 
mary nodule, being found, is then thoroughly curetted away. The 
whole cavity is now washed out with 1 : 3000 corrosive sublimate 
and is stuffed with iodoform gauze. The Esmarch bandage, if ap- 
plied, is then removed. The gauze is left in for one-half to three- 
quarters of an hour or until the next day, and is removed after 
being wet with a sublimate douche: the surface is dried, and the 
wound is sewed up with a sterilized continued suture under the 
most careful antiseptic precautions. An opening of some size is 
left through which the iodoform-glycerin is injected. If the gly- 
cerin does not flow well, it must be forced through a tube into all 
parts of the cavity, which should be filled sufficiently to expose the 
inner wall to the fluid without over-distention. The stitches should 
not be drawn too tightly, because they prevent healing by first 
intention. Finally, the wound is entirely closed and a dressing 
with gentle compression is applied. Those parts of the body where 
compression cannot easily be applied are not suited to this method, 
as slight hemorrhages from the walls of the cavity are apt to take 
place. 

Usually there are three or four days of fever with a high even- 
ing temperature. The dressing is allowed to remain, if all goes 
well, for two or three weeks. In other cases the fever and pain are 
so great that the dressings have to be removed, and the emulsion, 
mingled with blood, will be found oozing up between the stitches. 
In this case the emulsion must be pressed out and drains be inserted 
between the stitches, or the wound may be opened slightly and the 
blood be pressed out, and healing without suppuration may still 
occur. Billroth adopts this treatment also to open abscesses. 
Iodoform-poisoning is rarely seen. 

A 10 per cent, emulsion of iodoform in olive oil, or equal parts 
of iodoform and olive oil, may be used in many cases: such treat- 
ment is well adapted to open sinuses, and can safely be carried out 
by the patient himself. It is of course not so effective as one 
applied before the abscess is opened, but it gradually brings about 
an improvement in cases not amenable to treatment in any other 
other way, and it is useful in healing a sinus that may have re- 
mained after operation, or it is adapted to the preliminary treat- 
ment of open sinuses before attempting operative interference. In 
fact, the iodoform treatment is a valuable preliminary treatment to 
any operation that is intended, and the success which it has thus 
far met with, and the ease with which it can be carried out, even 



552 SURGICAL PATHOLOGY AND THERAPEUTICS. 

by those who have not the conveniences of a large clinic, recom- 
mend it strongly for general trial. 

In dropsical forms of tuberculosis of the joints (hydrops tubercu- 
losus) the effusion may be treated by the method sometimes em- 
ployed for non-tuberculous dropsy of the joint. This method con- 
sists in the introduction of a canula, and, after drawing off the 
fluid, injecting a solution of carbolic acid of the strength of i : 60. 
After manipulating the joint so that the fluid shall come in contact 
with the entire synovial surface the solution is drawn off and the 
puncture is covered with an antiseptic dressing. Great care must 
always be taken to procure strict asepsis during such an operation. 

There are a large number of cases of bone or joint disease 
which are not relieved by any of the methods of treatment 
hitherto mentioned. Formerly all these cases eventually came 
to excision or to amputation, but the present knowledge of the 
pathology of these affections, and the extent to which the differ- 
ent parts of the joints are involved in different cases, and the 
great security and precision offered by bloodless and antiseptic 
modes of operating, enable one to choose from a much greater 
variety of operative procedures. 

Resection of the joint will obviously be unnecessary where a 
tuberculous nodule exists in one of the epiphyses which it is 
desired to remove. It may be sought for and readily be found 
if a fistulous tract is present; otherwise an exploratory incision 
must be made for the purpose. A flap of skin with the peri- 
osteum may be reflected from the bone, and an exploratory punc- 
ture may be made with the chisel in several places until the nodule 
is discovered. In removing the disease care should be taken, if 
suppuration or cheesy degeneration has not already occurred, to 
cut into the healthy bone, and to avoid, if possible, bringing the 
diseased mass in contact with the healthy tissues. If the nodule 
has softened and broken down, the cavity must be scraped out 
thoroughly with a curette, and if there is a sequestrum present 
it must be pried out with an elevator. The walls may, if neces- 
sary, be chiselled down to healthy bone even at the risk of mak- 
ing an opening in the joint. The cavity thus made can then be 
disinfected with a solution of 1 : 1000 corrosive sublimate, or, if it 
is doubtful whether all disease has been removed, it may be seared 
by the actual cautery. Some operators, relying upon the thorough- 
ness of their operation, allow the space to fill with blood-clot after 
removing the Esmarch bandage, and then seek to obtain union by 
first intention; but there is always danger that a local return may 



SURGICAL TUBERCULOSIS OF JOINTS. 553 

thus be facilitated, for if there be any of the infectious material 
left behind, the blood-clot offers a most favorable soil for its devel- 
opment. It is better, therefore, to fill the cavity with iodoform 
gauze and allow it to heal by granulation. Senn suggests the 
introduction into such cavities of fragments of decalcified bone 
that have been covered with iodoform. These fragments offer a 
suitable scaffolding for the development of the granulations, and 
at the same time the iodoform diminishes the danger of local or 
of general tubercular infection. The danger of general infection 
must always be borne in mind whatever operation is being per- 
formed, for acute miliary tuberculosis may result from an infection 
of the surrounding healthy tissues of an operative wound. 

Tubercular nodules in parts of the skeleton remote from joints 
may be treated in the same way. A portion of the rib may be 
resected if necessary, or the surface of a flat bone may be trephined 
or chiselled until all diseased bone has been removed. 

When the diseased nodule or sequestrum projects into the joint, 
it may be necessary to open the joint to facilitate its removal. The 
operation to be performed in this case is arthrotomy. A number 
of such operations have been successfully performed. Arthrotomy 
consists in making an incision into a joint for the removal of a 
foreign or diseased body. It may be in the form of a large trans- 
verse cut which lays the joint open freely for inspection, or it may 
be a simple linear incision, or, finally, a flap of integument and 
perhaps of periosteum may be reflected for the purpose of expos- 
ing the seat of the disease. After removing the diseased bone, 
and, if need be, curetting some adjacent infected portion of the 
joint and dusting with iodoform powder, the wound is closed and 
a small drain or tent of iodoform gauze is allowed to remain be- 
tween the lips of the wound. After any such operation in or 
near a joint the limb should be placed upon a splint, so as to 
secure complete fixation during the early stages of the healing 
process. Such nodules are found in the anterior or in the lateral 
portions of the epiphysis of the tibia, in a condyle of the femur, 
in the neck or the trochanters of the femur, and in the olecranon 
process of the ulna; in nearly all of which cases it is not impos- 
sible to make an opening into the diseased cavity without involv- 
ing the joint. Several cases of exploratory incision into joints 
have resulted in their cure, very much as in laparotomy for tuber- 
cular peritonitis. 

In deciding upon some of the more serious forms of operation 
it should be remembered that the functional results after excision 



554 SURGICAL PATHOLOGY AND THERAPEUTICS. 

of the joint are inferior to those obtained by conservative treat- 
ment. Moreover, any operation which involves the epiphyseal 
line interferes seriously with the growth of bone. Although in 
tumor albus there may be an arrest of the growth of bone, the 
shortening after an extensive incision, as of the knee-joint, is far 
greater than after a spontaneous cure (Bradford). 

These operations should therefore be attempted only when, in 
children, considerable collections of pus are found in the joint and 
more or less profound constitutional disturbance exists, as shown 
by the presence of fever and weakness and loss of appetite. Con- 
siderable displacement of the bones also indicates an advanced 
stage of the disease. In adults, after a trial has been made of 
the various forms of conservative treatment, it is better to adopt 
a mode of treatment that will lead to rapid healing, rather than to 
run the risk of pulmonary tuberculosis or amyloid degeneration 
of the internal organs. The advent of suppuration with the 
formation of an abscess communicating with the joint that can- 
not be controlled by the usual treatment is apt to be followed by 
the establishment of fistulous openings of a tuberculous character 
and a hectic fever. Under these circumstances it would be unwise 
to postpone too long resection of the joint. The presence of a dis- 
location or subluxation in the hip must be an indication for resec- 
tion. In the knee a subluxation could probably be remedied by 
other means unless extreme in degree. 

The patient's station in life will influence the surgeon some- 
what in the selection of a mode of treatment. In a laboring man 
an operation leading to a cure in a few weeks' time may be selected 
in preference to a more conservative treatment, although the latter 
might be successful in the course of two or three years. 

Arthrectomy is an operation designed, as its name implies, for 
the removal of the structures forming the inner surface of the 
articular cavity. In its narrow sense it is limited to an excision 
of the synovial membrane, cartilage, or bone. The latter opera- 
tion has sometimes been called "atypical resection" or partial 
resection of the joint. The term " erasion of the joint" is used 
by English writers, but all these distinctions are confusing. The 
principal difference between this method and the typical resec- 
tion of the joint lies in limiting operative interference solely to 
the diseased structures. In arthrotomy the ligaments and even 
considerable portions of the synovial membrane may be preserved. 
In arthrectomy the periosteum and the contour of the bones are 
preserved, and, if new bone-formation takes place and the repair 



SURGICAL TUBERCULOSIS OF JOINTS. 555 

is all that could be desired, the joint retains it normal outline and 
sometimes its mobility. It is, moreover, not supposed to interfere 
with the growth of the limb. The objections to this operation are 
that it is not thorough, and that it fails oftener than excision to 
eradicate disease. In twenty-two operations for arthrectomy col- 
lected by Muller two patients died of general tuberculosis some 
months after the operation, in fifteen the wound healed by first 
intention, there was no shortening in six cases, and in two only 
was there a certain amount of motion possible. Senn reports two 
cases of arthrectomy of the elbow-joint, in both of which the 
"functional result was satisfactory." 

The technique of the operation consists in so laying open the 
joint, as performed in the operation for resection, that its interior 
shall freely be exposed. This opening is accomplished in the knee- 
joint by a transverse incision which divides the lateral ligaments. 
The patella should also be reflected back by free lateral incisions 
through the capsule, so as to expose the pouch which lies beneath 
it. The curette is usually not sufficiently effective in removing the 
tuberculous disease of the synovial membrane, as the diseased layer 
does not lie loosely over the surface as in cold abscess, but is part 
of a dense membrane from which it cannot be scraped. Every 
fragment of diseased tissue must carefully be dissected off with 
the forceps and scissors. Particular attention should be paid to the 
various folds of the capsule, and especially to the posterior layer 
which borders on the popliteal space, taking care to avoid the large 
vessels that lie very close to the external condyle of the tibia. 
If the bones are healthy, the synovial membrane alone should 
be excised; but if sequestra or fistulae leading to diseased bones are 
found, it may also be necessary to remove portions of the cartilage 
and bones. The patella should be allowed to remain if not dis- 
eased. Such an operation should of course be performed by the 
bloodless method and under the strictest antiseptic precautions. 
After removing the Esmarch bandage the oozing should be arrested 
by temporary pressure with corrosive sublimate gauze or with iodo- 
form gauze packed into the joint. A few vessels will require liga- 
ture, however. If the operator is satisfied that all diseased tissue has 
been removed, the joint may be closed, a small drain being allowed 
to remain a day or two in the corner of the wound. Some opera- 
tors after removing the bandage allow the blood to accumulate 
within the wound in order that healing by aseptic blood-clot may 
take place; but this should be tried only when it is desired to fill a 
space left by the removal of diseased bone, and when it is certain 



55 6 SURGICAL PATHOLOGY AND THERAPEUTICS. 

that all diseased germs have been removed. In doubtful cases 
Krause's method seems the most prudent. This method consists 
in the tamponade of the synovial cavity with iodoform gauze. 
All the pouches of the cavity should be filled with gauze which 
has been freshly rubbed in iodoform powder, and which may 
remain in sitic for a few days or even for two or three weeks. If it 
is desired at any time to remove the gauze permanently, the joint, 
if it is still aseptic, can be closed by secondary suture. The 
dressing may be changed from time to time if the secretion is 
excessive. Krause adopted this method in two cases of men over 
fifty years of age in whom there were extensive abscess-formation 
and burrowing of pus. In both cases healing took place without 
fistulse, and the patients reported themselves well a year and a year 
and a half, respectively, after the operations. Owing to the diffi- 
culty of laying open the joint thoroughly, arthrectomy is not well 
suited to all cases. It is best adapted to the knee-joint, and per- 
haps also to the elbow-joint, but in the shoulder, and particularly 
in the hip, the anatomical conditions make it no easy matter to 
gain access to the more remote portion of the synovial capsule. 
The preliminary treatment with iodoform, oil, or glycerin paves 
the way, however, for these more conservative methods of opera- 
ting, and although they cannot be considered as well established 
methods at the time of this writing, they have nevertheless a future 
and deserve a careful trial. 

Resecticm of the joints may be illustrated by a description 
of the operation upon the knee. The joint is opened by a trans- 
verse incision running from condyle to condyle. This cut may 
be made directly across the centre of the patella, which can be 
sawn through, or it may curve with the convexity either above 
or below that bone. Senn makes a curved incision through the 
skin above the patella, and, after reflecting the flap downward, 
cuts through the patella, which is united again by suture after 
the operation. The patella is, however, usually removed even 
when it is in a healthy condition. After the crucial ligaments 
have been divided the ends of the bones are made prominent 
by forced flexion of the limb, and they are sawn off at some 
point sufficiently removed from the surface to include all the dis- 
eased bone. In children the epiphyseal line should carefully be 
avoided, for, if this is removed, the growth of the bone will greatly 
be impaired. A thin section, sufficient to include the articular car- 
tilage, is usually all that is needed. Any remaining nodule can 
subsequently be curetted. The bones must be so cut that the limb 



SURGICAL TUBERCULOSIS OF JOINTS. 557 

will be straight when they are placed in apposition with one an- 
other, and care must be taken that the posterior edge of the tibia 
does not press against the popliteal vessels. After removing the 
elastic bandage the hemorrhage should be arrested by pressure, by 
elevation of the limb, and by tying such arteries as require the 
ligature. The bones can be held firmly together by a silver suture 
cut short and allowed to remain permanently. It is safer to em- 
ploy some form of drainage, as in the majority of cases union will 
be favored by conducting off the serous and bloody discharge of 
the first few days. 

In resection of the hip- and shoulder-joints the operator should 
not be satisfied with removal of the head of the femur or the hume- 
rus, but careful attention must be given to all other portions of the 
articular cavity, and all diseased tissue must carefully be removed, 
the incision being made sufficiently large for the purpose. In 
resection of the elbow-joint it is better to remove the bone freely 
and to avoid too careful preservation of the periosteum; otherwise 
ankylosis may occur. The results of such operations are usually 
excellent, and it is rare that a flail-like joint is obtained. 



XXVI. TUBERCULOSIS OF THE SOFT 

PARTS. 

i. Tuberculosis of the Skin. 

The identification of many forms of skin disease with tubercu- 
losis has been so satisfactorily demonstrated that no doubt exists at 
the present time of their true nature. 

Among the most prominent of these affections is lupus, which 
is now universally recognized as a tubercular disease, but, before 
Koch demonstrated the presence of the bacillus of tuberculosis in 
the lupus nodules, clinical observation had demonstrated the strong 
probability of its relation to tubercle. Brock found in 79 per cent, 
of the cases of lupus examined by him complications with other 
forms of tuberculosis, and Besnier showed that 21 per cent, of his 
lupus patients died of phthisis. Inoculations in animals have been 
made successfully from fragments of lupus, and Koch succeeded in 
obtaining a culture of the bacillus on blood-serum from a case of 
lupus hypertrophictis. 

Lupus is characterized by the formation in the skin of minute 
nodules of a reddish-brown color, more or less transparent and 
covered with epidermis. They appear to lie just beneath the sur- 
face, and they are well defined in outline. A cluster of papules 
about the size of a pin's head is first observed, and as the organ- 
isms grow they gradually approach one another, finally becoming 
confluent and forming nodules of considerable size. According to 
the direction which the growth takes there may be an almost 
infinite variety of forms. The varying degree of involvement of 
the upper layer of the skin gives rise to differences in the clini- 
cal appearances of the disease. These nodules are situated on the 
cheeks, on the nose, or on some other parts of the face; that is, in 
an exposed situation. They are very rarely found in the scalp, 
but are seen occasionally upon the limbs and trunk. 

Pathologically, the nodules consist of little granulation tumors 
in the true skin, in which tumors may be found all the elements 
of the miliary tubercle. The papillary layer is generally somewhat 
enlarged. The cutis vera and the papillae are infiltrated with 
leucocytes. The collection of cells in the true skin contains well- 
marked giant-cells. The infiltration in more advanced cases ex- 
tends sometimes to the adipose tissue. The bacilli are usually hard 

558 



TUBERCULOSIS OF THE SOFT PARTS. 559 

to find. Cornil and Babes examined microscopally twelve cases, 
and found a bacillus on only one occasion. 

In the ulcerating form of lupus there is a more intense inflam- 
mation of the superficial layer of the cutis and the papillae. The 
large numbers of leucocytes bring about a softening of these layers, 
and they break up the attachments of the cells of the rete mucosum. 
The epidermis, consequently, is thrown off and suppuration of the 
papillary layer takes place. 

The evidence that lupus vulgaris is a form of tuberculosis of the 
skin is sufficiently conclusive. As the disease progresses in the 
non-ulcerative form the growth takes place from the periphery, and 
there can occasionally be made out minute tubercular nodules in 
an early stage of formation. The older portions show a tendency 
to get well ; they lose their peculiar color, the swelling disappears, 
the epidermis peels off, and cicatricial tissue is left behind. 

When the infiltration is not deep the disease appears as a yel- 
lowish-brown discoloration of the skin without any elevation of 
the surface. The diseased part is somewhat softer than the healthy 
structure, and a probe can easily penetrate the tissue. This form 
is called " lupus maculosus." Later the nodule may be soft and 
gelatiniform, or it may contain little masses of colloid material in 
the form of cysts. In other cases the morbid tissue is very firm 
and extends deeply into the skin. This form is very slow in its 
growth, and never breaks down. It is a peculiarly obstinate form 
of the affection to deal with. In some cases the tubercular nodules 
seem to be surrounded with an almost cartilaginous induration. 

As cicatrization goes on and the upper layers of the skin are 
destroyed, considerable desquamation occurs: this may be a suf- 
ficiently marked characteristic of the affection to receive a special 
name. This condition is sometimes known as squamous or exfo- 
liating lupus. 

When the lupus nodules break down and the cheesy degenerated 
material is thrown off there is presented the ulcerating type, or 
lupus exedens. The ulcers are covered with thin brownish crusts 
and the surrounding skin has a brownish-yellow color. The mar- 
gin of the ulcer will be raised if the tubercular growth has been an 
active one. In this type the growth is somewhat more rapid. 

When, however, the infiltrated tissues of the skin break down 
gradually, cicatrization may begin in the centre of the diseased 
area; and, as the process continues to infiltrate and destroy the sur- 
rounding healthy skin a serpiginous ulcer is formed. As the disease 
proceeds there is sometimes an exuberant formation of tissue which 



560 SURGICAL PATHOLOGY AND THERAPEUTICS. 

produces a papillary growth. These papillary growths may be de- 
veloped from granulations which have become covered with epithe- 
lium. The names lupus hypertrophicus and lupus framboisioides 
are given to these forms. When lupus is situated on the lower 
extremities, the formation of this tissue is so excessive that the 
limbs are greatly enlarged, forming a species of elephantiasis. 

These two principal forms of lupus are not necessarily distinct: 
the non-ulcerating form may in time ulcerate. The parts become 
inflamed and softened and ulceration takes place. If ulceration 
occurs with great rapidity, there may be phagedenic lupus, but 
this type is exceedingly rare. 

Although lupus is principally confined to the skin, it may spread 
to the deeper parts and the periosteum may be attacked. The dis- 
ease may spread along the lymphatics and involve the adjacent 
glands; it may become multiple, attacking several portions of the 
skin at once. Pulmonary tuberculosis may eventually develop as 
a secondary complication, but this affection of the skin is a very 
chronic one, and it usually remains confined to that structure; it 
may spread, however, to the mucous membranes. Lupus of the 
face may spread to the mucous membrane of the mouth and the 
nostrils. The nostrils may become contracted, and sometimes may 
nearly be obliterated by the cicatricial tissue. The disease may 
reach the auditory canal and attack the membrana tympani; the 
conjunctiva, and even the cornea, may become involved in the 
disease. 

Lupus presents certain aspects peculiar to certain localities. On 
the face the disease begins as the macular variety, and finally forms 
one or more separate nodules. As these nodules spread and cica- 
trization takes place extensive surfaces may become involved, and 
the whole face may be transformed into a cicatricial and discolored 
tissue. Lupus of the nose generally occupies the tip and the alse. 
The reddened and hypertrophied tissue is covered with ulcers and 
crusts and gives rise to great deformity. The disease is found also 
on the lips and the external ear. On the limbs and body it assumes 
the warty and serpiginous forms, and it is frequently accompanied 
with great hypertrophy of the tissues. 

Lupus usually begins in childhood, and with such trifling lesions 
that it often passes unnoticed until at the period of puberty it 
springs into new life, and a rapid development of the disease with 
destruction of the affected part is observed (Van Harlingen). 

Tuberculosis vera cutis, which is a rare affection, is usually sec- 
ondary to disease elsewhere. It starts always from one of the 



TUBERCULOSIS OF THE SOFT PARTS. 561 

mucous membranes and spreads over the adjacent skin. It begins 
as minute nodules in the skin that soon break down and ulcerate. 
A circular or an oval ulcer of variable size is formed. There are 
usually several ulcers, which may run together and assume a ser- 
piginous form. They are found most frequently near the anus, on 
the lips, near the nostrils, and on the upper extremities. They 
are seen only in individuals in advanced stages of pulmonary tu- 
berculosis. They are usually devoid of pain. Esmarch describes 
such ulcers near the anus, which are, however, very painful, par- 
ticularly at the time of a movement of the bowels, if they encroach 
upon the mucous membrane. They may sometimes be quite large 
and may be multiple. They are usually associated with pulmonary 
disease, and are probably the result of intestinal infection. The 
lupoid ulcers described by Allingham are probably of this variety. 
Leloir lately reported a hybrid affection of lupus and syphilis. In 
certain cases he found a nodule which healed to a certain point 
with specific remedies, and then for its entire disappearance re- 
quired treatment appropriate for tuberculosis. 

Scrofuloderma, which is an affection of more frequent occur- 
rence, corresponds to the gommes scrofuleitses dermiques of French, 
writers. It is always associated with some other unmistakable 
signs of general tuberculosis, such as affections of the glands, the 
bones, or the joints (Zeisler). It is the ulcerated form which is 
usually said to be tuberculous. The commonest seat of these 
nodules is on the face, in the submaxillary region, on the neck and 
thorax, and on the extremities. They are often found near a 
softened lymphatic gland. They appear at first as a discoloration 
of the skin, which becomes raised and forms a nodule that spreads 
slowly, and finally softens at one or more points; or it may appear 
subcutaneously and gradually involve the skin. Finally small col- 
lections of pus form beneath the surface of the diseased skin, which 
is much discolored. When these cavities open a thin yellowish or 
sanious pus is discharged, leaving pouches covered with a thin 
layer of skin. A flat superficial ulcer or a deep fistulous cavity may 
form in this way. The granulating surface is gelatinous and is of 
a pale yellowish color. Extensive serpiginous ulcers may thus de- 
velop that leave behind them disfiguring scars. Occasionally they 
coexist with deep-seated nodules of a tubercular nature. They 
occur at all periods of life, but chiefly at puberty. 

There is another class of tubercular lesions of the skin that 
appear to be the result of direct local inoculation. These types 
are not usually associated with generalized tubercle, and are essen- 

36 



562 SURGICAL PATHOLOGY AND THERAPEUTICS. 

tially local affections. Zeisler classifies under this head four varie- 
ties : namely, (a) Verruca necrogenica, or anatomical tubercle ; (b) 
Tuberculosis verrucosa cutis (Riehl and Paltauf); (c) Tuberculosis 
papillomatosa cutis (Morrow); and (d) Tuberculous ulcerations. 

(a) Anatomical tubercle, which is found on the fingers and the 
dorsal surface of the hand of persons in the habit of handling dead 
bodies or in performing autopsies, is undoubtedly the result of local 
inoculation. It begins as a small red nodule, which becomes pus- 
tular and is soon covered with a scab. Gradually it spreads on the 
surface, becomes thicker, and is covered with papillary growths, 
giving it a warty appearance. It has a well-defined margin. Here 

.and there on its surface are seen small points of pus which can be 
squeezed out from the deeper layers. In some cases it is quite pain- 
ful; at times it is very indolent in character. It may spread through 
the lymphatics to the forearm and the axilla, and in some instances 
may give rise to a fatal visceral tuberculosis. 

(b) Tuberculosis verrucosa cutis is classified by most writers with 
anatomical tubercle. It is situated on the dorsal surface of the 
hands and the fingers and in the interdigital spaces. It varies in 
size from a dime to a silver dollar. When fully developed a patch 
consists of three concentric zones. The peripheral zone is erythe- 
matous, the color disappearing under pressure of the finger. The 
second zone is formed of* little pustules or of scales covering pus- 
tules ; the skin is of a reddish-brown color and is somewhat infil- 
trated. The central zone, which is raised 2 to 3 millimetres above 
the level of the skin, is covered with papillary growths which are 
largest at the centre. Between the warty growths are fissures and 
small skin-abscesses from which can be squeezed a few drops of 
pus. The growth is very sensitive. The lesion is situated in the 
superficial layers of the cutis, and it rarely extends to the level of 
the sudoriparous glands. Riehl and Paltauf found large numbers 
of the bacilli of tuberculosis in the diseased tissue. The affection 
is seen in vigorous individuals who are brought by their occupation 
in contact with domestic animals. It is very slow in development, 
and it may last from two to fifteen years. Bowen has described 
examples of this affection. In one case infection occurred in one 
of the Transatlantic cattle-ships. He also describes a number of 
cases of this disease occurring in young subjects and on different 
portions of the body, as on the elbow, the wrist, and the knee. In 
all cases there appeared to have been a local inoculation. Micro- 
scopical examination of specimens taken from some of the lesions 
showed the characteristic giant-cells and bacilli. 



TUBERCULOSIS OF THE SOFT PARTS. 563 

{(■) The tuberculosis papillomatosa cutis is an isolated case 
described by Morrow, the result of an infection of the skin of the 
face from pre-existing tubercular disease of the bone. The case 
was remarkable for the extent and the amount of the warty tuber- 
cular growth, which involved the cheeks, the upper lip, the nose, 
and the eyelids. The hypertrophic condition of the growth and 
the papillary excrescences were marked features of this case. 

(d) Tuberculous ulcerations produced by inoculation appear on 
any infected locality. An example of this form occurs in the pre- 
puce after the rite of circumcision when the fresh wound is sucked 
"by the operator and is infected with the saliva. Repeated instances 
of this form of inoculation have been reported. Infection may 
occur while washing the linen of consumptives. Brown describes 
a case of tuberculosis verrucosa cutis on the back of the finger of 
the right hand of a woman. The disease appeared at the time of 
the death of a daughter whose soiled handkerchiefs and clothing 
the mother had been in the habit of washing. Ulcerations have 
formed after piercing the ears. In all these ulcerations an exami- 
nation has shown the characteristic giant-cells and bacilli. Most 
tuberculous affections of the skin, except those seen in advanced 
general disease, can be cured. Lupus, however, is distinguished 
from all other tubercular diseases of the skin by its marked tend- 
ency to relapse. 

The general treatment of tuberculosis of the skin is the same in 
many cases as that adopted for the disease in other parts of the 
body. Although the general condition of the patient may be good 
in lupus, in some forms of cutaneous tuberculosis there is more or 
less cachexia. In any case it is of importance to sustain the 
patient's health. Cod-liver oil is one of the best remedies for this 
purpose. Bucq, who considers it the most important internal rem- 
edy for this disease, recommends from four to eight tablespoonfuls 
daily. Among other drugs, arsenic may be mentioned as one of 
the most efficacious. It may be administered in the form of Fowl- 
er's solution. 

For local treatment antiseptic agents have been recommended 
since the nature of the disease has been recognized. White em- 
ploys a solution of bichloride of mercury, 1 or 2 grains to the ounce, 
applied half an hour every morning or evening on compresses kept 
continually wet, or the same drug may be used as an ointment in a 
strength of 2 grains to the ounce, applied continuously and renewed 
twice a day. Care must be taken to avoid salivation, which, how- 
ever, is unlikely to occur if the patient is watched. White noticed 



564 SURGICAL PATHOLOGY AND THERAPEUTICS. 

rapid improvement at first, and he obtained permanent cures by 
this method, in some cases after several months of treatment. He 
also used with satisfactory results from 2 to 4 per cent, solutions of 
salicylic acid in castor oil. 

The objection to this antiseptic mode of treatment is that the 
agents are not always brought in direct contact with those parts in 
a stage of active growth. To accomplish this contact it may be 
necessary to use caustics as a preliminary treatment. Among these 
caustics pyrogallic acid is supposed to have a mild but effective 
action. It may be used with ether in a saturated solution on a 
compress ; or it may be sprayed on and afterward covered with 
collodion; or it may also be employed as an ointment. After the 
tubercular nodule has been melted down in this way, mercury in 
the form of a plaster or an ointment may be applied. Iodoform, 
one of the most effective poisons to tubercle, may be employed 
locally. It may be applied in the form of a powder or an oint- 
ment or in an emulsion with glycerin, or it may be forced into 
the soft tissues by boring, or it may be injected with a hypo- 
dermic needle. 

Now that the nature of the disease is known, attempts should 
always be made to treat it as if it were a malignant growth. 
Operative procedures are therefore indicated in a large number of 
cases. There are of course certain regions where excision cannot 
be performed, as on the alse of the nose or in extensive disease of 
the face. The curette or scarificator or the actual cautery may be 
used in these cases, either alone or as an aid to other forms of 
treatment. 

The soft nature of tuberculous tissue enables the curette to sink 
easily into it, so that it may thoroughly be scraped away in many 
cases. It is well to follow up the sharp spoon with some form of 
caustic. The mildest of caustics is nitrate of silver, which in the 
form of a pointed stick can be made to search out the various rami- 
fications of the disease. When the diseased tissue is firm and unyield- 
ing, it may be exposed by means of scarification, which can be per- 
formed with the lancet or by an instrument specially devised for the 
purpose. After the deeper parts of the diseased tissue have thus 
been laid bare they may be treated with the antiseptic remedies 
already mentioned. Scarification is said to leave a better scar than 
the cautery. In certain parts of the face the actual cautery is one 
of the most efficient agents for removing the disease immediately 
without too great loss of tissue. The cicatrization prepared by 
nature often leaves less deformity than when excision has been 



TUBERCULOSIS OF THE SOFT PARTS. 565 

performed and an attempt has been made to bring the edges of the 
wound together by sutures. 

Whenever the disease can be excised it is undoubtedly the most 
efficient way of dealing with it, and is the one least likely to be 
followed by relapse. 

The reputation lupus has for relapse is due to the imperfect 
methods of eradicating the disease. Even when the wound is so 
large that the edges cannot be brought together, the surgeon should 
not hesitate on this account, as there is presented in the Thiersch 
method of skin-grafting an efficient way of covering the solution 
of continuity. Large operations of this kind necessitate anaesthe- 
sia, but the smaller forms of tuberculous nodule may be excised 
after local anaesthesia has been produced by subcutaneous injection 
of a 1 per cent, solution of cocaine. 

2. Tuberculosis of the Mucous Membranes. 

Only a certain number of these affections are accessible to the 
surgeon. Primary lupus of the mucous membrane is compara- 
tively rare. In by far the greater number of cases it is second- 
ary to disease of the skin, and proceeds thence to the mouth, 
the pharynx, the conjunctiva, etc. The small reddish-brown 
nodules are not observed in the mucous membrane; instead, 
there are seen minute white points in the livid red and slightly- 
thickened membrane. There is a superficial loss of cells which 
can hardly be called ulceration: later these white spots disap- 
pear and the surface becomes papillary. Lupus of the pharynx 
may be seen independently of cutaneous lupus. Ulceration may 
finally take place, and the ulcers, which last a long time, after 
partially healing break down again. The ulceration may ex- 
tend until it involves almost the whole thickness of the mucous 
membrane. 

There are forms of tuberculosis of the throat and soft palate 
that are not regarded as lupus. This form of the disease is 
seen as a large superficial ulcer, or ulcers which eventually run 
together. They have a yellow surface, and they may extend over 
a large portion of the posterior wall of the pharynx and soft palate. 
Miliary nodules may be seen lying in the membrane between the 
ulcers. It closely resembles syphilis, for which it may be mis- 
taken. The extensive adhesion of the velum to the pharynx and 
the occlusion of the posterior nares are more frequently due to 
tuberculosis than to syphilis. These cases are often combined 
with pulmonary tuberculosis, but many cases are amenable to 



566 SURGICAL PATHOLOGY AND THERAPEUTICS. 

treatment with the curette, with caustics, or with the actual cau- 
tery, combined with the local application of iodoform powder. 

Tuberculous ozcena occurs independently of lupus, and it ap- 
pears in the form of ulcerations. This affection is not to be con- 
founded with the ordinary so-called "scrofulous ozcena." The 
formation of ulcers occurs chiefly on the turbinated bones. They 
are irregularly shaped with a yellowish purulent surface. They 
appear to be caused by infection from the pocket handkerchief con- 
taining the dried sputa of the patient. 

Tuberculous tumors of a polypoid shape are occasionally found 
attached to the septum. They resemble sarcomata, but they are 
infiltrated with tubercular nodules. As they grow they may per- 
forate the septum. Their point of origin usually enables one to 
distinguish them from polypi. 

Tuberculosis of the tongue occurs partly in the shape of ulcers 
which sometimes are torpid and sometimes are of the fungous 
variety. It appears also as a nodule which breaks down in the 
centre. Isolated ulcers may be mistaken for cancer, but they can 
generally be distinguished from that disease by the inflammatory 
infiltration of the tissues which always accompanies tuberculosis. 
Volkmann, however, has twice extirpated such growths under the 
impression that they were cancerous. The nodular form may also 
be mistaken for syphilis, but in the later stages the cheesy suppu- 
ration serves to distinguish it. With the aid of cocaine fragments 
of tissue can always be removed from the tongue for the purpose 
of microscopic investigation: the exploratory punch is particularly 
well suited for this purpose. Examples of this affection are not 
common in America. The writer has seen but one well-marked 
case of tuberculosis of the tongue. The apex and about one-third 
of the lateral half of the tongue were involved in an inflammatory 
swelling, a portion of which was ulcerated. This case was under 
observation for several months while the patient was treated with 
injections of tuberculin. On the borders of the ulcer minute 
whitish tubercles could be seen during the periods of exacerbation 
of the disease. In this patient there were slight rales at the apex 
and a tubercular abscess at the anus. The improvement in the 
general health was marked during the treatment, and, although 
after several months of treatment the nodule had not diminished 
in size, yet a permanent cure was finally effected. 

The disease may be treated by excision of a wedge-shaped piece 
of the tongue or by the actual cautery. In several cases reported 
by Volkmann there was subsequent pulmonary tuberculosis, 



TUBERCULOSIS OF THE SOFT PARTS. 567 

although other cases were permanently cured by the operation. In 
two cases, which he examined post-mortem, the whole surface of 
the tongue was covered with small flat ulcerations the size of a 
pin's head, which ulcers in many places became confluent. Dur- 
ing life these ulcerations were supposed to be aphthous. 

Volkraann has seen non-lupoid tuberculous ulceration of the lip on two 
occasions. In one case, that of a young girl with multiple cutaneous tuber- 
culosis, the ulcer was removed by a V-shaped incision . In the second case, 
that of an old woman, the disease had been mistaken for cancer and had been 
treated with superficial cautery. This ulcer was also excised. A case is 
reported of a woman, thirty-two years of age, who contracted an ulcer on the 
inner and outer surface of the lip from her husband, who was suffering from 
a tubercular ulcer of the gum. 

A considerable number of cases of fistula in ano are of a tuber- 
cular nature. As is well known, this affection is often associated 
with pulmonary tuberculosis. These fistulse can be distinguished 
from the non-specific variety by their tendency to form fungous 
granulations and sinuses in the mucous membrane and the skin. 
When these sinuses develop externally their tubercular nature is 
apparent by the pale, gelatinous character of the granulations and 
by the reddish-purple color of the thin skin which covers them. 
They may at times be very extensive, extending out for a consid- 
erable distance into the nates. The skin is thin, discolored, and 
undermined for a considerable distance. On pressure cheesy-like 
masses and a thin serous pus ooze from the fistulous opening. 

As long as the disease is confined to the mucous membrane there 
appears to be no increase in size of the glands in the inguinal region, 
but as soon as the margin of the anus or the skin is affected these 
glands are sometimes found to be enlarged. This affection usually 
begins in the mucous membrane of the rectum as the result of an 
infection through some slight bruise or fissure. An ulcer rarely 
forms here, as is usual in other parts of the intestinal canal when 
tubercular infection takes place, but the result of this local inocu- 
lation is an ischio-rectal abscess. The bacilli are carried through 
the intestinal canal, as has already been seen, and they are thus 
brought to this locality. Occasionally a primary infection of this 
perirectal tissue may occur through an intravascular route, but 
the disease is most commonly developed secondary to pulmonary or 
buccal or intestinal tuberculosis. The disease must be treated with 
the same attention to the necessity of removing all tuberculous tis- 
sue as in case of tuberculosis in the bones. The membrane should 
be curetted away thoroughly, and each sinus should carefully be 
followed to its termination. The wound should then be stuffed 



568 SURGICAL PATHOLOGY AND THERAPEUTICS. 

with iodoform gauze. Attempts at excision with subsequent sutur- 
ing of the wound are more liable to be followed by a recurrence of 
the disease. The presence of disease in the lungs is not necessa- 
rily a contraindication to the operation. In incipient pulmonary 
phthisis there is no objection to surgical interference, as it is now 
known that distant parts of the body are not affected by any such 
operations, as was formerly supposed to be the case. A somewhat 
analogous form of tubercular infection is observed in the region of 
the appendix and caecum. Here also there is a certain amount of 
stagnation of the intestinal contents, and therefore slight injuries 
to the mucous membrane are likely to occur. Another peculiarity 
common to both regions is the presence of loose connective tissue 
immediately outside the intestine. This tissue is found behind the 
caecum as well as around the lower portion of the rectum. For 
this reason, perhaps, the disease is less confined to the mucous 
membrane, and it takes the form of an abscess which breaks and 
leaves a fistulous opening. A certain number of the cases of appen- 
dicitis that come to suppuration are of tuberculous origin. In these 
cases is found a fistula containing fungous granulations which may 
involve the skin, and it heals with difficulty. Tuberculosis of the 
mucous membrane of the rectum may occur in the form of small 
tubercles which break down and form small round ulcers. These 
tubercles run together, forming ulcers, often of considerable size, 
that may be recognized by their eaten-out edges, by their irregular 
surface, and by the presence of fresh gray and yellow softened nod- 
ules in the borders, base, and neighborhood of the ulcer. As the 
disease progresses there may form a circular or girdling ulcer of 
the rectum which leads to stricture if an attempt is made at cica- 
trization. In most cases the process spreads slowly and involves 
the muscular tissue, and perforation may take place into the peri- 
toneal cavity or into the surrounding connective tissue, forming 
abscesses and sinuses. 

Tuberculosis of other portions of the intestinal canal is not 
infrequent as the result of a primary infection of the membrane 
by impure food or as the result of a secondary infection from the 
lungs through tuberculous sputa which have been swallowed. 
This form of tuberculosis rarely falls to the surgeon's lot to 
operate upon unless perforation or obstruction should occur, in 
which case laparotomy, and even intestinal resection, might be 
called for. One or two such cases have been reported. The result 
of intestinal tuberculosis is not infrequently an infection of the 
peritoneum. 



TUBERCULOSIS OF THE SOFT PARTS. 569 

3. Tubercular Peritonitis. 

Tubercular peritonitis occurs at all periods of life. It is com- 
mon in childhood, but is seen most frequently between the ages of 
twenty and forty. This disease is most prevalent among females, 
although of 21 cases reported by Osier 15 were males, and in 46 
cases examined post-mortem in the Munich Pathological Institu- 
tion $$ were males and only 13 were females. 

There are three types of this form of peritonitis : (1) acute mili- 
ary tuberculosis of the peritoneum, characterized by a sudden onset, 
a rapid development, and a serous or sero-sanguineous exudation; 
{2) chronic caseous and ulcerating tuberculosis, characterized by 
larger tuberculous growths, which tend to caseate and ulcerate, 
leading often to perforations between the intestinal coils, and by a 
purulent or sero-purulent exudation, often sacculated; (3) chronic 
fibrous tuberculosis, in which the process may be subacute from 
the outset, or it may represent the final result of the miliary form. 
Little or no exudation occurs in this variety, and the tubercles are 
hard and pigmented (Osier). 

The peritoneum may be infected, secondarily, through the in- 
testines, the Fallopian tubes, and possibly from the pleura through 
the diaphragm or from the mesenteric glands. It may also become 
infected, secondarily to pulmonary tuberculosis, through the circu- 
lation. The disease may also occur primarily in the peritoneum, 
but this is rare. 

From the intestine infection may take place through tubercular 
ulcerations, as there is always a formation of miliary tubercles on 
the surface of the peritoneum over the ulcers when these reach any 
considerable size, and from this point a general infection may take 
place. The bacilli often develop in the lymphatic vessels of the 
intestine without causing ulceration, and they are carried by these 
vessels to the mesenteric glands. 

In many cases the infection remains localized in some portion of 
the peritoneal cavity. The commonest seat of this limited tuber- 
culosis is the region of the pelvis in the recto-vaginal or recto- 
vesical fossae. When the tubercular virus enters the peritoneum it 
may be spread about by the peristaltic movements of the intestines 
or it may tend to gravitate to some one of the pelvic pouches. 
Localization may be maintained by adhesions of the peritoneal 
surfaces, which adhesions are sometimes very extensive. The 
Fallopian tubes are probably a frequent source of tubercular peri- 
tonitis, although the tubes may be infected from the peritoneum. 
Tubercular salpingitis is a complication often found in this disease, 



57° SURGICAL PATHOLOGY AND THERAPEUTICS. 

for Osier estimates that in from 30 to 40 per cent, of the cases the 
tubes are affected. In many cases of laparotomy for removal of the 
tubes these organs are found diseased, while the peritoneum is still 
healthy. In some cases the disease spreads through the diaphragm 
and involves the pleura. This complication occurred in only three 
out of seventeen cases. 

When infection takes place through the mesenteric glands 
they become enlarged, the tubercles making their way through 
the capsules of the glands, or the diseased glands undergo cheesy 
softening, and some of the broken-down material is discharged 
into the peritoneal cavity. Such enlarged glands in young chil- 
dren are often accompanied with distention of the abdomen and 
marasmus, the condition being known as tabes mesenterica. In 
most of these cases there is probably more or less tubercular peri- 
tonitis. Some of these glands may grow so large as to give the 
appearance of an abdominal tumor. Gardner reports such a case 
in a man aged twenty-one. Colin describes three cases in soldiers, 
in whom were found enormous tubercular tumors of the mesen- 
teric glands. In the majority of cases the extension of the process 
in the peritoneum goes on slowly, and it is accompanied by a for- 
mation of connective tissue: in this way thick and extensive adhe- 
sions form. 

When the omentum is involved in the process the contractions 
which accompany the formation of adhesions cause the omentum 
to be retracted into a thick, firm lump, which lies transversely 
across the abdomen just above the umbilicus. A more or less 
abundant effusion takes place at the same time. The fluid is either 
greenish-yellow and turbid, or in more acute cases it may be serous 
or sero-sanguineous. In some cases the exudation may be purulent 
in character. Owing to the simultaneous development of adhe- 
sions these exudations become sacculated. The omental enlarge- 
ments and the encysted collection of fluid often give rise to the 
appearance of a tumor growing at some point in the abdominal 
cavity. In ninety-six cases collected by Osier of this kind 3 per 
cent, were supposed to be cases of ovarian or other form of tumor. 
These sacculated exudations may be found in the upper part of the 
abdominal cavity, emanating from the region of the liver, the 
gall-bladder, or the spleen. They may be seen also in the middle 
part of the abdomen. Here occasionally a cystic accumulation 
occurs between the layers of the omentum, assuming at times 
enormous dimensions. Such an accumulation would probably be 
mistaken for an ovarian tumor. 



TUBERCULOSIS OF THE SOFT PARTS. 571 

These exudations may occur also within the pelvis, in which 
case the disease almost always starts from the Fallopian tube: the 
coils of intestine immediately become glued together about the dis- 
eased spot and shut it off from the general peritoneal cavity. In 
this way there form extensive pus-cavities which give rise to 
symptoms of acute inflammation. When the abdominal cavity is 
opened to relieve these symptoms the intestines are found studded 
with tubercles. A number of such cases have occurred in the 
writer's practice, of which cases the following is an example: 

A woman twenty-seven years of age had been slowly losing weight for 
two years when an attack of menorrhagia, with the formation of a tnmor in 
the right iliac region, brought her to the hospital. She remained in the hos- 
pital for two months under medical treatment, during which time she 
improved so much that she was discharged. Eight months later she returned 
in a bad condition. There was general abdominal distention, a temperature 
of 102 F., and fluctuation in the right iliac and pubic regions. An incision 
on the median line showed the intestines everywhere matted together and 
studded with gray and yellowish nodules, some of which on removal were 
found to be true tubercles. There was no serous exudation. On separating 
the pelvic adhesions a pint of very foul pus was evacuated. A drain was left 
in, and the patient made a good recovery. There was no sign of tubercu- 
lar disease in any other part of the body. When seen a year later she re- 
ported that she was in good health and had married. 

The matting together of several coils of intestine may form an 
almost solid movable tumor not unlike a uterine fibroid. The dif- 
ficulty of diagnosis in such cases is very great. 

Owing to the distortions of the coils of intestines by the pres- 
ence of adhesions the mucous membrane may ulcerate and per- 
foration may occur. It is quite possible also that symptoms 
of obstruction may be produced by extensive adhesions of this 
nature. 

Many cases of supposed tubercular peritonitis are not really 
tubercular. Welch describes fibroid or lymphomatosis nodules 
occurring in chronic serous peritonitis. J. F. Payne describes a 
case of minute fibrous granulations of the peritoneum associated 
with growths throughout the liver, possibly syphilitic. A careful 
examination of the nodules should therefore always be made if 
possible, and the presence of the bacilli be determined either by 
the microscope or by inoculation experiments on animals. 

Tubercular peritonitis is an affection which shows itself by no 
well-marked and constant clinical symptoms. Its onset is often 
very insidious. The infection may take place so slowly and so 
painlessly that the patient may not have presented a single symp- 



572 SURGICAL PATHOLOGY AND THERAPEUTICS. 

torn of abdominal disease. The onset may, however, be sudden 
and be accompanied with all the symptoms of acute peritonitis. 
Slight fever, occasional vomiting with alternate constipation and 
diarrhoea, may be the first group of symptoms. On examination 
of the abdomen the intestines are found distended with gas, and 
the presence of ascitic fluid may be recognized in the lower por- 
tion of the peritoneal cavity. When the exudation takes place 
rapidly it is often mixed with blood. When the gastric symp- 
toms are very marked the disease may simulate cancer of the 
stomach. There is often a typhoidal condition which, with con- 
tinued fever, may lead to the supposition that the patient has 
typhoid fever; but occasionally there is found a subnormal tem- 
perature throughout the course of the disease. 

The prognosis of the disease is exceedingly unfavorable. It is 
either an indication that the system is suffering from a general 
tubercular infection or that disease of other organs may follow in 
its track. Thus there may be pulmonary tuberculosis as a sec- 
ondary infection. In the graver forms there may be found exten- 
sive amyloid degeneration of the internal organs. 

It is now a well-recognized fact that many cases recover spon- 
taneously; it is even possible that the disease may run a latent 
course, and a cure may take place without a sign of the exist- 
ence of peritonitis. There is certainly no improbability in the 
involution of tubercles of the peritoneum as in other portions of 
the body. The tubercles undergo fibroid and pigmentary indura- 
tion and the exudation is absorbed. A certain number of adhesions 
are all that is left to mark the site of the disease. The cases most 
likely to terminate favorably are those in which the infection is 
limited to the peritoneum and is of only moderate extent. 

The good effects of laparotomy in the treatment of this disease 
are now generally recognized. In 1862, Spencer Wells performed 
laparotomy for what was supposed to be an ovarian tumor. He 
found a tubercular peritonitis. The effusion was withdrawn and 
the patient recovered. Since then cure has followed many such 
mistakes in diagnosis. In 1884, Z. B. Adams opened the peri- 
toneum for purulent peritonitis, probably of tubercular origin, 
and evacuated a large quantity of pus, the patient being alive 
and in good health ten years later. In a case of explora- 
tory laparotomy performed by Halstead tubercular peritonitis was 
found, and the cavity was washed out with a sterilized salt solu- 
tion and drained. The patient made a good recovery. Several 
months later, the patient having died of pneumonia, an examina- 



TUBERCULOSIS OF THE SOFT PARTS. 573 

tion showed the tubercles still present and containing bacilli, but 
undergoing a fibroid change. 

The cases best suited for operation are those in which the dis- 
ease is confined to the peritoneal cavity — those with fresh eruptions 
and considerable effusion. When the Fallopian tubes are exten- 
sively diseased and the tuberculosis has involved the uterus or has 
spread through the diaphragm, or there is any evidence of pul- 
monary disease, the conditions are unfavorable. When the puru- 
lent stage is reached the chances of recovery are in many cases 
poor, but the evacuation of circumscribed collections of pus is 
always indicated unless there is grave constitutional disturbance. 

Why laparotomy with drainage produces such a radical 
change in the peritoneal cavity has not yet been explained. 
It has been suggested that the curative action is due to the 
removal of the ptomaines which accumulate in the ascitic fluid. 
The operation undoubtedly produces a profound disturbance in 
the processes of nutrition of this membrane, and under these 
circumstances the soil may no longer be favorable for the growth 
and dissemination of the bacilli. The absorbent action brought 
about by traumatic inflammation, so common elsewhere, may 
make itself felt on such an occasion, and it may favor the 
removal of the broken-down products of the disease. 



4. Tuberculosis of the Genito-urinary Organs. 

Disease of this region in women occurs in about 1 per cent, of 
all cases of autopsies for tuberculosis (Winckel). Tuberculosis of 
the Fallopian tubes can occur primarily, but it may also occur 
secondarily to uterine or to peritoneal disease, or it may accom- 
pany disease of the lungs and the intestines. It is found in child- 
hood, but it occurs most frequently in early adult life, and it may 
follow the puerperal state. Usually both tubes are involved. When 
both uterus and tubes are affected the tubes are generally more 
diseased than the uterus. It appears that in most cases the disease 
begins at the peritoneal end of the tubes, and works its way down- 
ward through the uterus to the vagina. The affection begins as a 
catarrh of the mucous membrane, in which are seen minute gray 
or yellowish-gray nodules. The canal is more or less distended 
with muco-purulent material. Ulceration takes place later, and 
with the breaking down of tissue the tube is filled with cheesy 
masses. The ulceration may result in perforation of the wall of 
the tube. In advanced stages the tubes appear coiled and dis- 



574 SURGICAL PATHOLOGY AND THERAPEUTICS. 

tended and much thickened and indurated. Calcification may- 
take place in the degenerated tissue. 

The uterus, as has been seen, is usually affected secondarily to 
the Fallopian tubes, or the bacilli may enter from the peritoneum 
through the tubes without involving the latter. In a certain 
number of cases the disease is undoubtedly primary in the uterus, 
and it is said by some to result from the entrance of bacilli 
during coitus. In a case described by Post the patient with a 
tuberculous testicle had a purulent discharge from the urethra, 
which on examination was found to contain large numbers of the 
bacilli of tuberculosis. Tuberculosis may follow the puerperal 
condition, and it is then found at the site of the placental inser- 
tion. In this case it is probable that the disease is transmitted to 
this region from some point in the interior of the body. Many 
writers concede an intravascular infection of the genital organs in 
both sexes. The disease is found in the early stages at the fundus, 
and it works downward in nearly all cases. In some advanced 
stages the uterus is enlarged and the cavity is filled with caseous 
material. The surface of the membrane is roughened and ulcer- 
ated, and, although miliary tubercles may be invisible to the 
naked eye, a microscopical examination reveals the presence of 
giant-cells and epithelioid cells. The cervix is rarely affected. 
Cornil and Babes found in six autopsies of cases of tuberculosis 
of the uterus three in which the bacilli were abundant ; they 
were difficult to find in the other three cases. Their experience 
in the examination of the tubes was about the same. 

The disease in the vagina is most frequently the result of an 
infection through the secretions which form in the tubes or uterus. 
It may, however, follow a tubercular peritonitis without infection 
of the tubes or the uterus. A few cases of primary tuberculosis 
of the vagina have been observed, but they are exceedingly rare. 
If the uterus is not involved, the urinary organs or the intestine 
will probably be found diseased. The vagina may become infected 
by a perforation of a tubercular ulceration of the rectum through 
the recto-vaginal septum. Cornil and Babes found bacilli in 
tuberculous ulcerations surrounding a recto-vaginal fistula, but 
were unable to find the bacilli in two other cases of tuberculous 
ulcer of the vagina. The tubercles are seen in the early stages of 
the affection on the mucous membrane of the vagina as small gray 
nodules or as larger masses with cheesy, ulcerated surfaces. They 
are situated in the middle or upper portions of the vagina. 

Tuberculosis of the vulva does not appear to be a common 



TUBERCULOSIS OF THE SOFT PARTS. S75 

affection. Cay la reports a case of tubercular ulceration of the 
labia and the ostium vaginae in a case of advanced pulmonary 
tuberculosis. Cases of lupus of the vulva have also been de- 
scribed. It is conceivable that infection might take place from 
tubercular discharges both from the vagina and the rectum. In 
many cases of tuberculosis of the lungs and the intestinal canal 
the vagina has been found affected, while the uterus and the tubes 
were in a healthy condition. This fact suggests an infection from 
the rectum through the anus and the vulva. When an organ is 
affected with tuberculosis, surgeons are accustomed, in deference 
to tradition, to assume that the disease has been transmitted to it 
from the lungs or the intestines. Hegar suggests, in addition to 
the possibility of a direct infection of the sexual tract during 
coitus, an infection by fingers and instruments during a vaginal 
examination. Gonorrhceal infection of the mucous membrane robs 
it of its epithelium, and a favorable soil is thus offered for the 
growth and spread of the bacilli. Such gonorrhceal inflammation 
may spread through the uterine mucous membrane to the Fallo- 
pian tubes. In this and in other ways the virus may gradually 
spread from the original point of infection through the genital 
tract. It may also be transmitted from the primary lesion through 
the rich uterine lymphatic plexus to the peritoneum, and thence 
find its way through the Fallopian tubes into the uterine cavity. 

If disease of the uterine tract were suspected, a diagnosis might 
be established definitely by a microscopical examination of the 
vaginal secretion, and the presence of the bacilli thus be deter- 
mined. The enlarged and thickened tubes could be recognized by 
bimanual palpation. The swollen tube may form a tumor the size 
and shape of a goose-egg, or it may have an elongated sausage-like 
feel to the touch. In other cases it may be felt as a series of 
nodules strung together. In some cases the tubes may be so sur- 
rounded and covered by an adhesion and exudation that it is 
impossible to detect them. Their situation is often changed. 
They may be displaced into Douglas's cul-de-sac, where they are 
frequently fastened by adhesions. An enlargement of the uterus 
might suggest the infection also of that organ. Curetting the 
inner cavity of the uterus might yield material for a microscopical 
examination. 

The local treatment of tuberculosis of the uterus and the vagina 
consists principally in antiseptic douches, and in the application of 
iodoform to the diseased surfaces after the use of the curette or the 
cautery. Inasmuch as the tubes seem to be affected primarily in 



576 SURGICAL PATHOLOGY AND THERAPEUTICS. 

the majority of cases, the recognition of tubercular salpingitis 
before the other organs were involved would be of importance. 
Laparotomy for the removal of tubes affected with tubercular dis- 
ease has frequently been performed with satisfactory results. 

Tuberculosis of the ovaries is much rarer, according to Klebs, 
than tuberculosis of the uterus and the tubes, and the former dis- 
ease does not occur simultaneously with the two last-named affec- 
tions. Klebs infers that it must become infected, therefore, through 
the circulation. Quite a number of observers have found diseased 
ovaries in connection with tuberculous uterine disease. Mosler 
found tuberculosis of the ovaries seven times in a series of forty- 
six cases of tuberculosis of the female genital organs. The organs 
are enlarged to the size of a hen's ^gg y and are filled with numer- 
ous nodules and cheesy masses. Some cases of tuberculosis of 
ovarian cysts are reported. The surface of the cyst is, in this 
case, studded with subperitoneal tubercles. In two cases reported 
the adjacent peritoneum was affected in one and the tubes in the 
other. Klebs reports a case of ovarian cyst with tubercles on the 
inner surface in which the infection seems to have proceeded from 
the uterus. It is not probable that this is the route usually taken, 
but that the ovaries are affected either primarily or simultaneously 
with the tubes. If the diagnosis of tuberculosis of the ovaries were 
made, it would be proper to remove them. 

In tuberculosis of the genital organs of man the bacilli, accord- 
ing to Cornil and Babes, are not easily found. In cheesy degenera- 
tion of the testicles and in epididymis it is often the case that none 
are obtained. Kocher, however, was able to find bacilli in the 
periphery of a tuberculous nodule, but not in the pus. 

Tuberculosis of the testicle usually begins in the epididymis, and 
when seen in the early stages it appears as a nodule which is hard 
to the touch, and in section as a grayish-red, firm, homogeneous 
mass that has no well-defined boundary, but shades off into the 
surrounding connective tissue. In this tissue are seen the round or 
oval or shrunken cylinders of the canals. As the disease progresses 
a number of these nodules form. The canals are filled with broken- 
down material and are distended considerably. Occasionally, when 
these nodules soften, there form in the adjacent tissue small abscesses 
which frequently break and become fistulous openings. 

In the testicles the disease shows itself at first as one or two 
large nodules which may involve the whole or a large part of the 
organ. These nodules soften down in the centre and form small 
abscesses, which also break and form fistulse. When the testicle is 



TUBERCULOSIS OF THE SOFT PARTS. S77 

affected secondarily to the epididymis, there are found a number of 
small nodules in the otherwise normal tissue of the organ. When 
the whole testicle is involved, a section shows it to consist of the 
gelatinous homogeneous tissue, in which lie several yellow cheesy 
masses of stellate or irregular shape. According to Kocher, a 
microscopical examination of the tubercles in the earliest stage 
of their development shows within the seminal ducts a collec- 
tion of giant-cells and epithelioid cells supported between the two 
layers of the membrana propria and filling out the lumen. The 
tuberculosis begins, therefore, as an intracanalicular process. As 
the intracanalicular masses undergo cheesy degeneration the new 
tubercle is found in the membrana propria. In some cases the 
membrane seems to be the part chiefly affected, the amount of cell- 
formation in the ducts being comparatively slight. The neighbor- 
ing ducts in this case rapidly become involved. In other cases the 
stroma seems to be the part in which the disease is situated; but 
as early stages of this process are not seen, it is probable that even 
the stroma is not in these cases the primary seat of the disease. 

In many cases the testicle is no doubt the region in the genito- 
urinary apparatus where tuberculosis begins. The bacilli have 
been found in the seminal ducts and in the semen of patients 
affected with pulmonary tubercle in whom the testicles showed 
no sign of disease. The organisms are carried to the organ in this 
case through the blood-vessels, and are transported through the 
epithelium of the canals into the lumen. The localization of 
the disease in this organ may be produced by trauma; Simmonds 
demonstrated this by experiment on a rabbit. An emulsion of 
tubercular sputum was introduced into the peritoneal cavity of the 
animal, and a few days later there was produced a contusion of the 
left testicle. The organ swelled somewhat at first, but the swelling 
subsided in a short time. Two months later the rabbit was killed, 
and a general miliary tuberculosis was found, with a broken-down 
nodule of considerable size in the left testicle. Gonorrhoea is not 
an infrequent predisposing cause of the disease. In fifty-two cases 
of tuberculosis of the testicle Kocher found that in fourteen cases 
the patient had suffered from gonorrhoea. In Simmonds' sixty 
cases eleven had had gonorrhoea. 

The question is often discussed as to the direction the disease 
takes in the genito-nrinary organs. Does it ascend from the 
urethra or the testicle to the kidney? or does it originate in the 
kidney and descend through the uro-genital tract? Rokitansky 
and other more recent authorities are of the opinion that the dis- 

37 



57§ SURGICAL PATHOLOGY AND THERAPEUTICS. 

ease ascends from the testicle, but Virchow takes the opposite 
view. Tubercular disease of the urinary organs is rarely found in 
connection with disease of the testicle. Tuberculosis of the testicle, 
although it is rare as a purely primary disease, is often found with- 
out tuberculosis of other portions of the genito-urinary apparatus. 
Primary affection of the kidney, with subsequent disease of the 
testicle, is not so rare as it is usually supposed to be. 

Nevertheless, the usual mode of progression is an ascending one. 
That is, the disease is transmitted from the testicles to the cord, and 
subsequently to the prostate. From this point it may be transmitted 
to the bladder and the kidneys, but this is by no means frequent. 
An infection of the other testicle occasionally takes place. It is 
possible that disease of the testicle may give rise to a miliary 
tuberculosis, and, although this is only a possibility, it is never- 
theless to be taken into consideration in deciding upon the propri- 
ety of removing the testicle. Salleron, in a series of fifty-one cases 
of tuberculosis of the testicle and the epididymis, found other organs 
affected in only one case. 

Coming now to the symptoms of the disease, it will be found 
that it is observed principally in youth and in early manhood, but 
it may also be found late in life. The disease, as has already been 
seen, begins in the epididymis or the testicle as a painful swelling, 
which reaches its full growth in a few days or weeks, and it is fol- 
lowed in a short time by the formation of an abscess and the estab- 
lishment of a fistula which may remain unhealed for several years. 
The progress is not always rapid, and the swelling may last several 
months before suppuration takes place. A long interval may 
elapse before the other testicle is affected. The local tuberculosis 
may occur without any sign of disease of the lungs or of the uri- 
nary organs, although the prostate usually will be found involved. 

The vas deferens is frequently enlarged, and it may be felt as a 
cylindrical cord or as a chain of nodules. This enlargement may 
extend for a few centimetres from the epididymis or it may be fol- 
lowed to the ring. It is rare that an effusion takes place into the 
tunica vaginalis. The walls are more frequently glued together by 
an adhesive inflammation. 

The infection of the vesicula seminalis follows disease of the 
vas deferens. It may also follow disease of the bladder. The 
walls of the duct are thickened and infiltrated and its cavity is 
distended with cheesy pus. When in this condition the vesiculae 
can easily be felt per rectum : they may reach the size of a walnut. 
Abscesses may form and discharge both into the rectum and the 



TUBERCULOSIS OF THE SOFT PARIS. 579 

bladder. Weichselbaum found a perforation of one of the larger 
veins of the pudendal plexus by a tubercular abscess of one of the 
seminal vesicles. The prostate is usually affected at the same time, 
and chiefly on the corresponding side. Abscesses may form and dis- 
charge through the perineum. 

From the prostate the disease may extend to the bladder and 
produce multiple ulcerations. The presence of tuberculosis is the 
cause of frequent and painful micturition and perhaps haematuria. 

An examination of the urine for the bacilli (see p. 58) will usu- 
ally settle the diagnosis. Tuberculosis of the bladder rarely occurs 
in women : according to Klebs, it is seen only in the male bladder, 
as the chance of a progression of the disease from the vagina or the 
vulva is infinitely less than from the prostate in man. 

Tuberculous ulcers, however, have been seen in the female 
bladder. Albers reports a case of small tubercular nodules near 
the urethra and in other parts of the bladder. The left ureter was 
filled with tubercle, and there was tubercular degeneration of the 
medullary tissue of the left kidney. Winckel, Hewitt, and Scan- 
zoni all report similar cases. Two of Winckel' s cases were second- 
ary. In one case the disease of the bladder followed that of the 
lung; in the other it was preceded by disease of the kidney and the 
ureter. The kidneys are often involved in the form of pyelitis or 
of cheesy nephritis. 

Tuberculous disease of the testicle is so often followed by ab- 
scess and fistula that the diagnosis is not usually difficult to estab- 
lish. The so-called " scrofulous testicle " presents a clinical picture 
sufficiently characteristic. The scrotum is swollen and reddened, 
or it is perforated by several fistulae, and the testicle and its adjacent 
structures are found thickened and enlarged. When suppuration 
has not yet taken place the diagnosis is more difficult. The disease 
can be distinguished from syphilis, as the peculiar stony hardness 
of the syphilitic testicle is not present. A chronic enlargement of 
the testicle coming on after a slight trauma or without history of 
injury is suggestive of tuberculosis, and this suggestion will be 
strengthened if there is any evidence of tubercular disease else- 
where. 

The disease runs a milder course in old people than in early 
life. It may be confined entirely to the testicle, and may be cured 
without the involvement of any other organ, but it has been seen 
that it frequently spreads locally and that it may be followed by 
miliary tuberculosis. Although it is possible for a cure to take 
place without operation, the function of the testicle is probably 



580 SURGICAL PATHOLOGY AND THERAPEUTICS. 

destroyed in all cases. For these reasons the removal of a tubercu- 
lous testicle is strongly advocated by most surgeons. Castration is 
advised even when the vesiculce seminales and the prostate are 
involved, as it has been observed that disease of these organs as 
well as of the bladder has undergone speedy improvement, and 
finally a cure has been effected. Castration is therefore indicated 
in young people when there are no evidences of advanced kidney 
or of lung disease. In older people the chance of a cure by local 
treatment is much better. It has been the writer's experience that 
many cases, even in young people, when the course of the disease 
has not been too acute, do well without operation. Andrews states: 
• ' I have repeatedly ventured in Illinois, where tuberculosis is far 
less prevalent than on the sea-coast, to take the patients through 
the whole affection without other operation than the lancing, 
drainage, and cleansing of the abscesses; and the patients have 
ultimately done excellently well and no infection of the lungs or 
the prostate followed." This experience has certainly been the 
writer's in several cases. Salleron mentions but two deaths in the 
fifty-one cases already mentioned. When the local inflammation is 
severe, however, and there is considerable constitutional disturb- 
ance, an operation is advisable. Such a case occurred to the writer 
recently in an overworked professional man. The testicle was at 
first much enlarged and there was considerable effusion into the 
tunica vaginalis. A few months later an abscess formed and the 
scrotum became greatly swollen and reddened. There were great 
debility and an evening rise of temperature. No tuberculosis could 
be discovered in any other portion of the body. Removal of the 
testicle and a portion of the cord, which appeared to be healthy, 
was followed by rapid improvement, and the patient now — several 
years after the operation — is in excellent health. In some of the 
less acute types of the disease the sinuses may be curretted thor- 
oughly and dressed with iodoform. Careful attention to the gen- 
eral health and to the surroundings of the patient is of great im- 
portance. The old-fashioned recommendation of a long sea- voyage 
is often followed by excellent results. In young adults, however, 
when the disease comes on rapidly and an enlargement of the pros- 
tate and the vesiculse seminales can be felt in the rectum, castra- 
tion is certainly indicated. 

The presence of tuberculosis of the bladder is a grave compli- 
cation. In some cases, however, a cure may be obtained by gen- 
eral treatment, combined with such remedies as have a curative 
effect upon the vesical catarrh which accompanies the disease. 



TUBERCULOSIS OF THE SOFT PARTS. 581 

Operative interference is hardly indicated. In the female it 
would be possible to reach and to cauterize the ulcers by means 
of vaginal cystotomy. Applications could also be made through 
such an opening to the diseased surface of the bladder. Supra- 
pubic cystotomy might enable the treatment to be carried on in 
the same way in man. These operations would, however, be indi- 
cated only in exceptional cases. 

Tuberculosis of the urethra, a very rare affection, is, according 
to Kanfmann, always part of a generalized tuberculosis. Infection 
takes place secondarily from the bladder or the prostate. The 
prostatic portion is frequently the part affected, and also, but less 
often, the membranous portion. 

Vettesen reports a case of tubercular ulcer of the meatus in a phthisical 
patient seventeen years of age. There had been painful micturition for 
some time ; an indurated ulcer occupied one side of the meatus and extended 
inward into the fossa navicularis ; the glands in the groin were enlarged ; 
there was enlargement also of the epididymis and the prostate ; bacilli were 
found in the secretions of the ulcer. At the autopsy there was found exten- 
sive urogenital tuberculosis: the right kidne}', the bladder, the prostate, and 
the bulbous portion of the urethra were affected. 

Hnglisch describes a tuberculous peri-urethritis in the deeper 
portions of the urethra. It may exist either inside or outside the 
deep layer of the superficial fascia. It begins with a discharge of 
a chronic character from the urethra, followed later by the forma- 
tion of perineal abscesses and fistulse. Some of the cases of incur- 
able "watering-pot perineum " are doubtless tubercular in nature. 
Langhans reports a case of polypoid tubercle situated in the ure- 
thra about one inch from the meatus. At the autopsy there were 
found extensive disease of both kidneys, ulceration in the bladder, 
and prostatic urethra. It might be mentioned here that Senn 
reports a case of tubercular ulcer of the dorsum penis that might 
easily have been mistaken for chancre, and he dwells upon the 
importance of remembering the possibilities of such a lesion in 
making a diagnosis. 

Tuberculosis of the kidney may occur either as a miliary tuber- 
culosis, as a part of a general infection, or as a nodule or tumor 
of considerable size. In " nephro-phthisis," as the latter form is 
called, there are in the renal tissue large caseons nodules which run 
together, and involve so large a portion of the organ that but little 
healthy kidney tissue can be found. Frequently the papillae are 
the parts first affected when the disease has invaded the pelvis of 
the kidney from below, the disease working its way along the 



582 SURGICAL PATHOLOGY AXD THERAPEUTICS. 

mucous membrane of the urinary passages. But the pelvis iu 
other cases may become infected secondarilv. As the tissue 
breaks down it is discharged into the pelvis, and the ureter inav 
become blocked with cheesy debris. In this way pyonephrosis 
may occur. There may be some enlargement of the kidney 
during the development of the disease, but it is offset bv the 
shrinking oi the cavities which form in its interior. Wedee- 
shaped tubercular infarctions are sometimes found which sug- 
gest the lodgment of an infected embolus, probably from the 
lungs. As the disease progresses there is frequently, as in the 
lungs, a mixed infection of the pyogenic cocci with the bacilli, 
and a suppurating inflammation hastens the process of disor- 
ganization. When this disorganization is completed the capsule 
forms a thickened wall or shell, from which spring septa, the 
remains of the connective-tissue stroma, the capsule enclosing a 
cavity communicating with the pelvis of the kidney. The walls 
of this cavity are lined with broken-down tissue and cheesy masses 
and remains of the kidney structure. When there is great dis- 
tention from obstruction abscess may form, or rupture into the 
peritoneal cavity may occur. 

The tubercular process may originate in the kidney as the 
result of tubercular disease in the lungs or elsewhere, or it may 
be the result of an ascending tubercular infection of the £enito- 
urinarv tract. The latter form of origin is far more common in 
men than in women. Tuberculosis of the kidney occurs at all 
periods of life, being found in children as well as in adults, but 
it is commoner in men than in women. 

The symptoms are those of chronic pyelitis, and they are in no 
way characteristic of tubercular disease. An examination of the 
urine, however, shows the presence of bacilli, and occasionallv 
also minute masses of cheesy matter in addition to pus, blood, 
and casts. If the urine is acid, it is probable that the kidney and 
not the bladder is affected. Inoculation experiments might settle 
the diagnosis if the bacilli could not otherwise be detected. The 
presence of lumbar pains and perhaps of an inflammatory swelling 
in the region of one kidney, or possibly a tumor, would point to 
that or^an as the seat of the disease. Loss of strength and emacia- 
tion, with anaemia, together with hectic fever, would be additional 
evidence in favor of tubercular disease. 

In the exceptional cases of isolated tuberculosis of the kidney — 
which cases are exceedingly rare — nephrectomy has successfully 
been performed. If there were indications of the presence of a 



TUBERCULOSIS OF THE SOFT PARTS. 583 

large pus-cavity in the lumbar region, an attempt might be made 
to open and drain and to treat the diseased surfaces with appro- 
priate remedies. The tubercular membrane would not, of course, 
be found in such a cavity, but a great deal of debris could be 
scraped away, and under favorable circumstances the patient might 
recover with a urinary fistula. This result, although it exposes 
the patient to the discomforts of such a fistula, leaves a larger 
secreting surface than would remain if one kidney had entirely 
been removed. 

5. Tuberculosis of the Mamma. 

Tuberculosis of the mamma is a rare disease. Recently Roux 
succeeded in collecting the records of 34 cases, in 2 of which the 
disease occurred in males. In 2 cases both breasts were affected. 
The ages varied from sixteen to fifty- two years. In only 3 cases 
was an injury supposed to have been the cause of the disease. In 
24 cases the disease was secondary to tuberculosis elsewhere. Man- 
dry collected 40 cases, in 21 of which there was histological proof 
of the tubercular nature of the disease. He found only 1 case in 
which the male breast was affected, which, he thinks, shows that 
the functional activity of the gland is important. The ages of the 
patients in his series ranged from seventeen to fifty-two years. Most 
of the cases seemed to develop shortly after confinement. In 8 
cases the patients had not borne children. In 17 cases the disease 
was in the right breast and in 8 cases in the left breast. In 7 cases 
no glands were noticed; in 17 cases there were enlarged glands, 
and in many of these fistulae had formed. The glands appear 
to have been affected secondarily, and not, as Konig suggests, 
primarily. 

According to Roux, infection appears to take place through the 
blood-vessels or the lymphatics, or by the breaking of tubercular 
foci which formed in the adjacent ribs or sternum. Roux also 
thinks that infection may take place through the ducts, and this 
appears to have been the mode of entrance of the virus in one of 
the writer's cases. A tubercular cavity about the size of an Eng- 
lish walnut formed near the nipple in a young unmarried woman 
about twenty years of age. A microscopic examination showed 
the presence of bacilli. The sinus was treated by curetting and 
an iodoform dressing, and it healed without further infection of 
the gland. 

According to most authorities, the principal form of tuberculo- 
sis of this organ is a primary disseminated or confluent type of the 



584 SURGICAL PATHOLOGY AND THERAPEUTICS. 

disease. There may also exist an isolated tubercular nodule. There 
is also the cold abscess in a certain limited number of cases. Ac- 
cording to Roux, there may be a secondary involvement of the 
organ due to disease in adjacent tissues. 

The tuberculous breast is sometimes enlarged and sometimes 
it is smaller than normal. It is often riddled with fistulse, and the 
nipple is usually retracted. Pale, flabby granulations protrude from 
the fistulous openings, and pressure brings out a thin pus with 
cheesy masses. It contains a number of irregularly-shaped swell- 
ings, which on section are found to be indurations of various sizes 
in which there are irregular cavities with prolongations running in 
various directions and communicating often with one another. The 
walls of these cavities are lined with a soft yellowish-gray mem- 
brane of varying thickness, and they contain cheesy debris. The 
surrounding tissue is much indurated, and is dotted over with 
miliary tubercles. When a large tubercular nodule forms in the 
breast, a lump is usually seen in the upper and outer quadrant 
extending to the axilla. The nipple is retracted and the axillary 
glands are enlarged. These nodules eventually break down and 
tuberculous fistulae form. In cold abscess the breast is more or less 
enlarged by a fluctuating tumor which is situated in the upper and 
outer quadrant and which appears to be secondary to suppurating 
glands. The lining membrane of such abscesses is the charac- 
teristic tubercular membrane. Miliary tubercles are rare in this 
situation. 

An abscess in this locality was once sent into the writer's ward as a case 
of malignant disease. An exploratory incision revealed its nature. Another 
case illustrated secondary infection of the organ. A large collection of pus 
had formed beneath the gland, and had already burrowed into the breast in 
several directions. The origin of the pus-cavity was a carious rib. It was 
necessary to turn up the breast by a curved incision along its lower border 
in order to reach the diseased bone and to check the burrowing of pus in the 
mammary gland. In a third case the abscess was situated in the lower hem- 
isphere of the breast of a girl eighteen years of age : a bacteriological exami- 
nation showed the presence of bacilli in the abscess-walls. The abscess was 
opened and healed readily under an iodoform dressing. 

Under the microscope are found a large number of small tuber- 
cles containing giant-cells in and around the tubercular nodules. 
Clusters of epithelioid cells are found in the interstitial tissue as 
well as in the acini. Many of the giant-cells appear to originate 
in the acini, and, according to Bender, they are of epithelial origin, 
as shown by Arnold to be the case in giant-cell formations in the 
heart and the lungs. 



TUBERCULOSIS OF THE SOFT PARTS. 585 

Patients are not usually aware of the beginning of the disease. 
Small nodules are accidentally discovered that grow slowly. In 
fact, the axillary-gland enlargement may have been noted first. 
As the nodules increase in size the skin becomes involved and the 
nipple retracts. The disease may last a long time without special 
change, but finally suppuration takes place and fistnlse form. The 
development of a cold abscess is almost without symptoms. The 
disease may be mistaken for a carcinoma which has suppurated or 
for a submammary abscess. Exploration with the punch or experi- 
mental inoculation would in most cases settle the question. In 
more than half the cases other organs are involved, but the prog- 
nosis is favorable if the disease is confined to the breast. 

When there is extensive disease of the breast with involvement 
of the axillary glands, and other organs are not involved, amputa- 
tion may be performed with, a careful dissection of the axilla. 
Attempts to treat the fistulse by curetting and the application of 
iodine are usually followed by a relapse. This clinical experience 
is in accord with the histological examination, which shows that 
the disease is not confined to the pus-cavities and fistulse. In cold 
abscess curetting may be performed, as in this case the disease is 
localized. The same treatment may be used for milder forms of 
the disease when only a limited portion of the gland is involved. 

6. Tuberculosis of the Lymphatic Glands. 

Tuberculosis of the lymphatic glands is a more common affection 
than any of those hitherto mentioned. In fact, it occurs both inde- 
pendently and in combination with all the forms that thave been 
described. All those types of disease formerly known as scrofulous 
glands are now recognized as genuine tuberculosis. In the Bleg- 
dams hospital in Copenhagen, out of 384 autopsies of children who 
died of acute infectious disease, 198 showed undoubted tubercu- 
losis, and in all these cases the glands were affected. 

The glands of different parts of the body vary greatly in their 
susceptibility. On the surface of the body the cervical glands are 
most frequently affected, next the cubital, and less frequently the 
axillary glands (Volkmann). The glands of the lower extremities 
are much less liable to disease than those of the upper extremity. 
Internally the bronchial glands are frequently involved, but the 
existence of such disease is often overlooked. In children the 
glands most frequently found diseased at autopsies are the cervical, 
the mediastinal, the mesenteric, and the retroperitoneal glands. 
Babes found the cervical, bronchial, and mediastinal glands affected 



586 SURGICAL PATHOLOGY AND THERAPEUTICS. 

in more than half of all the autopsies performed at the children's 
hospital at Buda-Pesth during eight years. 

When there is a predisposition to tuberculosis, simple enlarged 
or inflamed glands, due to catarrhal or to cutaneous affections, 
remain enlarged after these inflammations have subsided. These 
glands increase in size, soften, and are found, on removal, to be 
filled with tuberculous deposits. The two principal forms in which 
tuberculosis appears, large tuberculous foci with cheesy degenera- 
tion and miliary tubercles, can both be observed in perfection in 
the lymphatic glands, though the former type is the one most com- 
monly seen. 

When an enlarged gland is removed and is laid open with the 
knife, there is found hypertrophy of the glandular tissue that shows 
a pale transparent and uniform surface. In the centre are one or 
more cheesy masses the size of a ten-cent piece. A careful inspec- 
tion will show some thickening of the capsule and here and there 
a miliary tubercle. In a more advanced stage of the disease the 
cheesy masses soften down, and the cavity thus formed enlarges 
until nearly all the newly-formed glandular tissue has melted away, 
and finally the softened material breaks through the capsule of the 
gland and makes its way to the surface. 

A microscopic examination reveals the presence of giant-cells 
and epithelioid cells around the margins of the cheesy foci. In the 
miliary form well-marked examples of submiliary tubercle abound. 
The surrounding tissue shows merely the structure of hypertrophied 
glandular tissue. In the earlier stages of the process the bacilli are 
found, often in considerable numbers, as the soil appears to be 
favorable for their growth, but during the stages of suppuration it 
may be impossible in many cases to find a single bacillus. Never- 
theless, the inoculation of the cheesy material into animals always 
reproduces the disease. 

The most frequent seat of tuberculous adenitis with which the 
surgeon has to deal is the cervical region. The most common 
sources of irritation of the cervical glands, particularly in the New 
England climate, are the prevalent chronic catarrhs of the nose 
or the throat. Eczema of the face or the scalp, or chronic inflam- 
mation about the eyes and the ears, may also be the point of 
departure of the disease. These inflammations are rarely tubercu- 
lar, but they produce hypertrophy of the gland, which furnishes a 
fertile soil for the bacilli. The bacilli are readily grafted upon an 
inflamed skin or mucous membrane, and they can be carried 
thence through the lymph-stream to the adjacent glands. The 



TUBERCULOSIS OF THE SOFT PARTS. 587 

enlarged gland may, however, receive the bacilli from the circu- 
lating blood, the organisms having already obtained an entrance to 
the body elsewhere. The glands enlarge to the size of a walnut, 
and they can be felt as nodules lying beneath the skin, somewhat 
tender to the touch, but freely movable. They may remain in 
this condition for years, and may eventually disappear spon- 
taneously. More frequently they grow gradually, and, by the 
matting together of several glands from capsular inflammation, 
form tumors of considerable size. They are usually not painful, 
and they may remain without further change for a long period. 
They are not, however, absorbed. At some moment, when the 
patient's condition has become enfeebled, they begin to soften and 
to present some of the symptoms of inflammation, and they are 
much more tender to the touch. It is possible in such cases that a 
mixed infection has taken place and that true suppuration will 
follow. More frequently a chronic softening takes place, and 
fluctuation gradually makes itself apparent. At some point the 
skin finally becomes adherent to the tumor, changes in color to a 
purplish red, and finally perforation takes place, there being 
discharged either tubercular pus or a small amount of pus mixed 
with cheesy debris, and perhaps calcareous masses. Several such 
openings may occur, each of which communicates with a separate 
cluster of glands. The skin becomes undermined, and sinuous 
fistulae and pockets are formed which may extend even beneath 
the sterno-mastoid muscle. The covering to these cavities is a 
deep red or a purple color, and may be as thin as paper. When 
the skin is destroyed in this way, tuberculous ulcers form, which 
after healing leave the unsightlv scars so common in tuberculous 
or "scrofulous" subjects. 

The axilla is occasionally, though less frequently, the seat of 
tubercular adenitis. 

A young woman, seventeen years of age and in good general condition, 
presented herself at the hospital recently for the treatment of a sinus open- 
ing on the inner aspect of the short head of the biceps muscle. On probing, 
the sinus was found to communicate with a chain of glands in the axilla 
extending beyond the borders of the pectoralis major as far as the margin of 
the mammary gland. Several operations were performed on this patient : the 
glands were carefully dissected out, and she left the hospital improved in 
health. The following winter she returned, hoping to get some benefit from 
the tuberculin treatment. At this time the disease had not only returned in 
its original site in the right axilla, but it had also spread across to the 
opposite side. The supra- and infraclavicular glands on both sides were also 
involved, and her neck was riddled with tubercular sinuses. There was also 



SURGICAL PATHOLOGY AND THERAPEUTICS. 

marked cachexia. A few weeks later, marked symptoms of tubercular peri- 
tonitis having set in, the patient was carried home to die. 

The inguinal glands may occasionally also break down and 
simulate a venereal bubo. The scrofulous bubo, however, is, not 
associated with any lesion of the genitals. The origin of the 
glandular enlargement is generally attributed to a sprain. A 
gentleman consulted the writer for this affection, which he attrib- 
uted to a strain received while playing tennis. Volkmann reports 
a case of hemorrhage from the crural artery, the result of the 
breaking down of a mass of inguinal glands, and also a case of 
secondary infection of the peritoneum and pleura. 

The prognosis of tuberculosis of the lymphatic glands is in 
certain stages of the disease not unfavorable. As has been seen, 
there is discovered at many a post-mortem examination infected 
glands whose presence during life had not been suspected. The 
very large number of such cases leads to the supposition that at a 
given moment such glands may be present and may subsequently 
disappear: during the early stage of the glandular affection they 
are undoubtedly in many cases curable. When, however, the 
period is reached when several glands have become matted 
together, forming a visible tumor in the centre of which cheesy 
deposits have formed, the time has arrived for operative inter- 
ference. 

If operative treatment is carried out before suppuration is 
established, the glands can be enucleated from surrounding 
healthy parts. Every effort should be made to remove all frag- 
ments of diseased tissue. It is not sufficient to shell out a few of 
the most obvious nodules: all suspected structures should be 
dissected away, and the whole diseased tissue should be removed 
en masse if possible. Senn recommends division of the mastoid 
muscle for the removal of the deeper-seated glands, with subse- 
quent suture of the muscle. The disease should be regarded as 
one which must be treated by the surgeon's knife as rigidly as 
if the case were one of cancer. It is also of the utmost import- 
ance — and this point is almost invariably overlooked by operators 
— that the greatest care should be taken to avoid local infection 
of the exposed healthy tissues. The readiness with which the 
cheesy products of tuberculosis, when introduced into healthy 
animals, can reproduce the disease is proof of its virulent power. 
Carelessness in this respect doubtless explains many cases of 
relapse after operation. By thorough surgery the patient may 
not only be relieved of an annoying deformity, but may also 



TUBERCULOSIS OF THE SOFT PARTS. 589 

escape the dangers of pulmonary or of acute miliary tubercu- 
losis. Many a fatal case of tuberculosis had its origin in the 
"scrofulous" cervical gland. 

When suppuration is established and a cold abscess has devel- 
oped, it is not sufficient to open the abscess or even to curette care- 
fully its lining membrane. Usually a search with the probe will 
detect in the deep cervical fascia an opening, on dilating which 
the remains of an enlarged gland will be found as the source of the 
suppuration. This gland should carefully be removed, and the heal- 
ing process will thereby greatly be accelerated. When a small gland 
softens and suppurates and becomes adherent to the skin, the entire 
diseased mass can be included between two semi-elliptical incisions, 
and a clean wound will be left which can be brought together with 
sutures. When the skin is undermined by superficial pouches or 
by fistulous tracts, the diseased skin should be trimmed away with 
scissors, and the tuberculous granulations can then be thoroughly 
scraped. 

The importance of internal treatment in these cases need hardly 
be dwelt upon. Much may be accomplished in the milder forms 
of the disease with cod-liver oil, careful diet, and suitable environ- 
ment. Arsenic is supposed by some writers to have a certain 
specific action upon these glands. Nothing definite can yet be said 
on this point, but, as arsenic is also a useful tonic, it is at least 
worth a trial in cases where there is no great amount of cachexia. 
Iodide of potassium and syrup of the iodide of iron are also valu- 
able agents in certain cases. 

Primary tuberculosis of the connective tissue is rare. In the 
great majority of cases the disease is secondary to tuberculosis of 
the glands, bones, or joints. The burrowing of a cold abscess 
infects long tracts of connective tissue and fasciae. The primary 
affection occurs in the panniculus adiposus in small children. A 
number of small nodules form beneath the skin and run together, 
involving later the skin itself. These nodules are substantially 
the gommes tuberatleuses already described. Fluctuation is ob- 
served finally, and pus is discharged. Volkmann describes these 
nodules as the furuncular form of skin and connective-tissue tuber- 
culosis. Occasionally the pus may burrow and form a cold abscess 
quite independent of bone or joint. 

7. Tuberculosis of the Tendon-sheaths. 

Tuberculosis of the tendon-sheaths, or tendo-vaginitis tuber- 
culosa, may be either primary or secondary. The secondary form, 



59° SURGICAL PATHOLOGY AND THERAPEUTICS. 

which occasionally accompanies tubercular disease of a joint, is the 
variety that has been recognized as tubercular. Later studies have 
shown, however, that the disease may occur quite independently of 
any joint disease, and Garre has shown that it is not so rare as has 
been supposed. This observer met with twenty-five cases of the dis- 
ease in seven thousand cases seen by him in two and a half years. 

This disease occurs in two forms. Thefungotis form is charac- 
terized by the formation of an exuberant granulation tissue, which 
at times assumes the characteristic gelatinous appearance and en- 
velops the tendon within its sheath. At other times growths occur 
on the inner surface of the sheath, which growths become detached, 
forming the so-called "rice bodies," "melon-seed bodies," or cor- 
pora oryzoidea, as they are variously styled. This affection, known 
as hygroma, was supposed to be quite distinct from tubercular dis- 
ease, but it is now definitely established that the greater portion of 
these bodies contain tubercle bacilli. Similar bodies are found in 
the mucous bursse, and it has been proved, of some of them at 
least, that they are tubercular. These same bodies are found also 
in joints (hydrops fibrinosus), and they develop from the fibroid 
degeneration of tubercular granulations. There has been a great 
deal of speculation about these peculiar structures from first to last. 
Dupuytren, for instance, thought that they were hydatids, but the 
careful histological studies of late observers have definitely estab- 
lished their true nature. 

Primary tuberculosis of the tendon-sheaths occurs chiefly in 
adult life. It is commoner between the ages of thirty and forty 
than at any other period. The affection seems to follow some 
injury or sprain, and it is seen most frequently in laboring people. 
The right side is more frequently affected than the left, and the 
flexors more frequently than the extensors. In the fungous form 
of the disease the sheath of the affected tendon is lined with a 
grayish-red, highly- vascular tissue, which forms a long cylindrical 
rather firm connective-tissue growth. This growth distends the 
sheath of the tendon, and it is sometimes firmly attached to the 
tendon itself, the growth having penetrated its fibre. At other 
times the tendons can be dissected out clean from this tissue. The 
cavity of the sheath is usually not entirely obliterated, and occa- 
sionally rice bodies may be found in it, showing the relationship of 
this form to the other variety of the disease. The fungous growth 
may extend beyond the sheath of the tendon and invade the mus- 
cle. This complication is sometimes seen in the peroneal tendons. 
When examined under the microscope the walls of the tendon- 



TUBERCULOSIS OF THE SOFT PARTS. 591 

sheaths are found thickened by a small-cell infiltration in which 
are found giant-cells. The fibrous layer of the sheath gradually 
disappears, and it is replaced by fungoid granulations. The 
visceral or peritendinous layer is also often affected. The tendon 
in this case appears to be thickened, and its sheath is covered with 
a fibrinous exudation. Under the microscope there are seen on the 
surface tubercular products in a state of fibrinoid degeneration. 
Beneath these products there is a layer of highly-vascular granula- 
tion tissue containing giant-cells, and next the tendon there is 
either a loose connective tissue or the granulation tissue has pene- 
trated into the substance of the tendon itself (Garre). The number 
of tubercles varies: sometimes they are found quite numerous and 
arranged in rows, each one being encapsuled in a ring of connec- 
tive tissue. If the cavity of the sheath remains well defined, there 
may be seen several layers of endothelium upon it, but this is 
often worn away at the points of greatest friction, and there are 
found papillary granulations which probably are the beginning of 
the rice bodies. 

In the hygroma type the inner surface of the cyst has slight 
excrescences which have undergone fibrinoid degeneration. By 
friction these excrescences become pediculated, and they are 
entirely separated as rice bodies. They consist of a stratified or 
a structureless fibrinoid tissue which contains only a few cell- 
nuclei, but here and there is a giant-cell with tubercle bacilli. 
These bacilli are still capable of growth, and when the rice bodies 
are introduced into the tissue of animals tuberculosis may be pro- 
duced. In many cases the inoculation fails, showing that active 
bacilli are not always found in these bodies. The disease, thus 
produced, develops slowly, demonstrating that it takes a certain 
amount of time for the bacilli to be liberated from their somewhat 
dense capsule. The wall of the hygroma cyst is also found to be 
in a state of tubercular degeneration. Isolated tuberculous tumors 
are occasionally seen in the tendon-sheaths, similar to those already 
spoken of as occurring in the joints and in the nasal cavity. The 
cell-growth in these tumors is so large as to suggest in some cases 
sarcomatous tissue. 

The symptoms of the disease are quite chronic in character, and 
they develop very slowly, usually dating back to some injury. The 
swelling found at that time does not go down, but rather increases 
in size and becomes painful. The tumor is flat, oval, or sausage- 
shaped, and it is soft, elastic, and pseudo-fluctuating. In the case 
of hygroma the fluctuation is quite distinct. When the diseased 



^^H \^~ 



592 SURGICAL PATHOLOGY AXD THERAPEUTICS. 

tendons run beneath an annular ligament a constriction is found, 
giving the tumor an hour-glass appearance. The palmar bursal 
tumors of the hand belong to the hygroma type of the disease, and 
pressure above and below the annular ligament forces the rice bod- 
ies to and fro in a manner quite characteristic. The skin is not 
involved at first, but later, when suppuration occurs, it may become 
infiltrated, and ulcers and sinuses eventually are formed. This is 
more commonly the case in the fungous type. True cold abscess 
is rarely seen. When cicatricial contraction sets in the function 
of the tendon may seriously be interfered with. If the hygroma 
breaks externally, acute suppuration may follow, which greatly 
impairs the use of the hand. In some cases the joint over which 
"the tendons run may become involved in the disease. 

The tendons most frequently affected are those situated on the 
palmar and dorsal aspect of the wrist (Fig. 82). In the neighbor- 
hood of the ankle-joint is found the 
fungous form in the perineal sheaths, 
and also in the tibialis posticus and 
the extensor communis digitorum. 
Ulceration occurs here earlier than 
in the hand. The plantar surface of 
the foot is not affected. In the neigh- 
borhood of the knee-joint some of the 
tendons may be affected with this dis- 
ease, but here it is much less com- 
mon. 

Secondary tubercular disease of the 
tendon-sheaths is almost always of the 
fungous type. It is important to rec- 
ognize this complication in operations 
upon the joint: otherwise the diseased 
tissues may be overlooked. The dif- 
ferential diagnosis between the pri- 
mary and the secondary forms is often 
hard to settle if the joint happens to 
be affected. 

Fatty tumors are also rarely seen 
Fig. 82.— Tuberculosis of Tendon- in the tendon-sheaths under the name 
sheaths or Palmar Bursal Tumor. of lipoma arborescens. Sendler reports 

such a case in a girl fourteen years of 
age. The tumor occupied the sheaths of the extensor tendons of 
the hand, and when removed it appeared as a reddish-yellow lobu- 




TUBERCULOSIS OF THE SOFT PARTS. 593 

lated mass of fatty tissue with prolongations extending to each ten- 
don. Three months after the operation the patient died of pulmo- 
nary tuberculosis. Although in these cases the presence of tubercles 
does not appear to have been established by the observers, it is 
probable that these forms closely resemble the same tumor observed 
in the knee-joint in which miliary tubercles are found. Moreover, 
in another case there was a family history of tuberculosis, and in a 
third the patient was suffering from cachexia. 

Many of the forms of primary tuberculosis of the tendon-sheaths 
may be treated by excision of the diseased mass. 

A lady sixty years of age consulted the writer for tuberculosis of the 
sheaths of the peroneal tendons at their point of contact with the external 
malleolus. The disease extended nearly to the point of their insertion and 
some distance above the malleolus. She had suffered in her youth from 
caries of the rib. The tendons were exposed by an incision about five 
inches in length, and a long spindle-shaped gelatinous mass was carefully 
dissected out, leaving both tendons clean and bright. The wound, which 
was complicated by sinuses, healed slowly by granulation. Perfect motion 
of the joint was obtained. 

When the elastic tourniquet is applied these operations can be 
performed without hemorrhage and an elaborate dissection can be 
made. In the palmar bursal tumor the annular ligament may be 
divided, if necessary, and the tendons dissected out one by one. 
During the healing process the tendons appear to form new 
sheaths for themselves in the granulation tissue, and the func- 
tion of the tendons usually is but slighty impaired by the ope- 
ration. 

When this condition is secondary to joint disease the operator 
must pay careful attention to this complication in performing resec- 
tion of the joint. When resection is not indicated amputation is 
probably the only resource if the general condition of the patient 
will permit of such an operation. The prognosis is favorable in 
primary disease of the tendon-sheath, as the fibrinoid type of 
tuberculosis is not likely to be followed by metastasis. 

Tuberculosis of muscular tissue is very rare. A muscle may, 
however, be affected secondarily to disease of an adjacent bone. 

8. Scrofula. 

Scrofula is a name that was formerly given to a large propor- 
tion of the affections just described as tuberculous disease, and the 
question naturally arises whether there are any affections which 
should still be classed under this head. The name is derived from 
sus, scrofa, a sow, to indicate the peculiar fulness which the en- 

38 



594 SURGICAL PATHOLOGY AND THERAPEUTICS. 

larged lymphatic glands give to the neck. As is now known, 
these glands are tuberculous, but there still remains a class of 
inflammations that are not tuberculous in character, to which 
certain children are liable, and which some authors are still 
inclined to include under the head of scrofula. Landerer de- 
scribes two types of scrofulous patients — the torpid and the ere- 
thitic. The former is the type generally recognized in the so- 
called "scrofulous child." The complexion is usually of a pale 
blond or pasty hue; the hair is frequently red; the features are 
coarse, the eyes watery blue, the lashes long, the lips thick, the 
nostrils large, the expression dull, and the figure inclined to 
plumpness. There is a tendency to chronic inflammations of 
the eyelids or of the cornea. There is often nasal catarrh, with 
fissures about the lips and nostrils, and pharyngeal catarrh, with 
enlargement of the tonsils. Such patients are also afflicted with 
chronic inflammation of the ear, and are likely to have eczematous 
eruptions of the face and scalp. The glands of the neck are almost 
always enlarged. Such children have a tendency to catch cold 
easily, to suffer from bronchial catarrh, and they are a constant 
source of anxiety. 

In the second type the erethitic, the children are of dark com- 
plexion, nervous and restless. They possess the tendency to suc- 
cumb easily to conditions by which healthy children would not be 
affected. There is less tendency to enlargement of the glands, but 
the same susceptibility to chronic inflammatory processes exists. 

This seems a somewhat fanciful sketch. There is, however, 
this foundation for it : namely, that there exists a type of chil- 
dren who are subject to chronic inflammatory infections, and who, 
although they may not have an inherited predisposition to tuber- 
culosis, nevertheless are more susceptible to the virus than are 
those who have sound constitutions. It is possible, moreover, 
that many of these inflammations, and even glandular enlarge- 
ments, may be due to other microbes than the bacillus of tuber- 
culosis, and the observations and experiences of quite a number 
of observers appear to strengthen this opinion. 

Charrin and Roger studied an organism which produces a lesion 
similar to that produced by the bacilli of tuberculosis. They found 
in the liver and spleen of a guinea-pig which died in the labora- 
tory, not having been the subject of experiment, numerous minute 
granulations resembling miliary tubercles. On taking gelatin cul- 
tures from these they obtained at the end of forty-eight hours a 
whitish growth which grew for a few days without liquefying the 



TUBERCULOSIS OF THE SOFT PARTS. 595 

gelatin. Under the microscope the organisms appeared as movable 
bacilli from 1 to 2 fi in length. Inoculation of animals subcutane- 
ously produced a local tumor containing cheesy matter and accom- 
panied by a swelling of the adjacent glands. At the autopsies the 
spleen and kidneys were found enlarged and full of miliary nodules. 
A large number of experiments with this organism were followed 
by a constant result. PfeifTer describes also a short bacillus which 
when introduced into mice produces enlargement of the adjacent 
glands and nodules in the spleen and liver, and also in the in- 
testine. 

Cornil and Babes report two cases occurring at Bucharest of 
acute bronchitis accompanied by the formation of miliary nodules. 
In the first case there was also intermittent fever. At the autopsy 
miliary tubercles were found around the bronchi, which tubercles, 
when examined, were found to contain chains and clusters of oval 
microbes about 0.8/i in size. Cultures in gelatin produced a foul- 
smelling bacillus about 0.6/i in length. In the second case, in which 
there was no malaria, the same organisms were observed. 

Malassez and Vignal as early as 1883 described under the name 
of tuberculosis zoogloeica a disease microscopically resembling 
tuberculosis. In the centre of the nodules were found large 
zooglcea masses of a variety of different organisms, but no bacilli 
of tuberculosis. 

Zagari obtained gelatin cultures at ordinary temperature from 
tubercular nodules in a guinea-pig. A fragment of this culture 
introduced into the subcutaneous cellular tissue of another guinea- 
pig reproduced the same disease and the same organisms. Each 
nodule under the microscope appeared to consist of a collection of 
small round-cells, "infiltration" cells, and leucocytes. The bor- 
ders of the nodule were not well defined, but the growth spread 
irregularly into the surrounding tissue. Other nodules showed the 
epithelial type and occasionally also giant-cells. Signs of hyaline 
degeneration were found in the nodules and also in the neighboring 
tissue. In the centre of each nodule was a mass of peculiar gran- 
ular consistency which appeared like cheesy material. By a some- 
what complicated method of staining it was found that these central 
masses contained bacilli with rounded ends, 1// long, and also oval 
bacteria from 0.4-0.8// long and about 0.3/i wide. In the centre 
were long chains and threads ; at the periphery were short bacilli 
and isolated micrococci. In the surrounding granulation tissue 
there were small groups of micro-organisms, some of which were 
micrococci and some diplococci, arranged in coils or straight lines — 



596 SURGICAL PATHOLOGY AND THERAPEUTICS. 

all apparently phases in the growth of the same organism. After 
frequent inoculations the type changed to a finer miliary nodule. 
To reproduce the coarser nodules it was necessary to introduce 
small amounts of the culture into the intestinal canal or to subject 
the organism to the drying effect of the air, or to a lower temper- 
ature, or to a struggle with other organisms. Zagari thinks that 
this virus, which is evidently widely spread in nature, should be 
studied with reference to its occurrence in man. Some of the cases 
of peritonitis reported above were found not to be genuine tubercu- 
lar disease. 

It is highly probable that further study will show that the bacil- 
lus of tuberculosis is not the only organism capable of producing 
this type of chronic inflammation in man. Surgeons are, in fact, 
still but on the threshold of this line of investigation. 



XXVII. DISEASES OF BONE. 

i. Osteomalacia. 

Osteomalacia is a disease of the bones in adult life that occurs 
most frequently in puerperal women, but it is seen also in women 
who are not in the puerperal state and in men. It is characterized 
by a progressive softening of the bone-substance, giving rise to 
deformity and sometimes to fracture. The first change noticed in 
osteomalacia is a gradual absorption of the lime-salts from the outer 







v\ s 






* 



Fig. 83. — Trabecula of Bone in a case of Osteomalacia — on the left osteoclasts, and on the 
right osteoblasts (oc. 3, obj. D.). 



layers of the trabecular or those layers in direct contact with the 
medullary tissue. The portion of the bone thus decalcified is com- 
posed of fibrous or striated tissue in which are found the bone-cells: 

597 



59§ SURGICAL PATHOLOGY AND THERAPEUTICS. 

these cells, however, have changed somewhat in shape, having lost 
their prolongations, and some of them having entirely disappeared. 
The outline between the bony tissue which still remains in the 
centre of the trabecular and this altered tissue, which may be called 
"osteoid tissue," is said to be well denned. Sometimes the trabec- 
ular become quite irregular, presenting indentations or the so-called 
"Howship's lacunae." The bony trabecular become narrower and 
narrower, and they may disappear entirely as the disease advances, 
leaving the osteoid tissue, which in its turn may be absorbed by 
the action of the osteoclasts. In case of improvement, however, 
the lime-salts may be deposited again and the trabecular may 
assume their former condition. In well-advanced stages of the 
morbid process destruction and repair may be seen going on 
simultaneously, the osteoclasts causing absorption of the bony 
tissue, and the osteoblasts formation of new bone (Fig. 83). 

In the mean time the medullary tissue throughout the bone is 
undergoing a marked change. The fatty tissue of which it is 
mostly composed in adult life is infiltrated with round-cells, and 
there is also hyperarmia of the blood-vessels; which affection 
changes the tissue into one resembling the red marrow of infancy. 
This tissue appears to take on active growth and to deprive the 
surrounding bony trabecular of their lime-salts, and subsequently 
to break up and absorb the decalcified bone. The trabecular of the 
spongy bone are gradually absorbed, the Haversian canals become 
wider, and the cortical bone is soon converted into spongy bone. 
As the bony tissue gradually melts away there is little left but 
marrow and periosteum if the process continues long enough (Fig. 
84). Bones in which the disease has made much progress become, 
therefore, soft and yielding, and they are easily twisted out of shape 
or are broken, and they can readily be cut through with a stout 
knife. The cortical layer of a long bone like the femur sometimes 
becomes as thin as paper, and its marrow has a red, succulent, 
spongy look. Numerous hemorrhages often occur in the vascular 
medullary tissue, and pigment is deposited. This new tissue may 
at any time undergo mucous degeneration, many of the cells dis- 
appearing and a gelatinous intercellular substance taking its place, 
or it may appear as a yellowish fatty tissue. In some cases the gel- 
atinous softening takes place to such an extent that cysts form, 
sometimes of considerable size. Later it may resume its medullary 
activity and continue the destruction of the bone, for it would seem 
that it is owing to this unusual activity of the medullary tissue that 
the bone is deprived of its salts and is absorbed. 



DISEASES OF BONE. 



S ( )9 



Although osteomalacia is regarded as a degenerative process, 
the changes seen in the cellular structures closely resemble an in- 
flammatory process, so far as the formation of a granulation tissue 
is concerned; but there is not found other evidence of bone-inflam- 




Fig. 84. — Section of Femur in a case of Osteomalacia : below is the medulla rich in cells, and 
above, the periosteum (oc. 3, obj. A.). 



mation, such as the formation of new bone. One indication of a 
disturbance of nutrition is the chemical change seen in the bone in 
this disease. The presence of lactic acid in excess in the bones 
affected has been supposed by several writers to be the cause of 
the absorption of the lime-salts. At certain periods of the disease 
lactic acid has been observed in the urine. This acid was found to 
diminish greatly in the cases reported during convalescence, and to 
disappear entirely with cure. Lime-salts have been found to a 
very limited extent in the urine. A chemical examination of the 
bone shows marked diminution of the gluten, and there has been 
found in the urine an albuminous substance which has been sup- 



6oo SURGICAL PATHOLOGY AND THERAPEUTICS. 

posed to be connected in some way with this change. The signif- 
icance of these chemical changes, however, has not been suf- 
ficiently determined to throw any light upon the origin of the 
disease. 

It has been thought possible that the disease might be of bac- 
terial origin, owing to the fact that it is often found in damp 
dwellings and it has followed sudden drenching of the clothing. 
Animals improperly fed and kept in damp stalls have also suffered 
from the disease. In a certain prison in Prague the disease ap- 
peared to prevail. It is, in fact, more frequent in certain localities 
than others, and it is observed frequently in Bavaria, Westphalia, 
Alsace, and along the borders of the Rhine, but in other parts of 
Germany it is extremely rare. It is rarely seen in England and in 
America. According to Busch, in 1888 only one hundred and sixty 
cases of this disease had been reported. Eighty-five of these cases 
were women in the puerperal state, and all were between twenty 
and forty years of age. Frequent pregnancies and long nursing, 
with poor opportunities to obtain proper nourishment, seem to 
have been the condition most favorable for the development of the 
disease in these cases. An analysis of these cases shows that the 
pelvis and the spine are the parts most frequently affected, far more 
so in puerperal cases than in non-puerperal women and in men. In 
the latter class all regions of the skeleton were affected, but in both 
classes of cases the disease was found less frequently in the head 
than elsewhere. 

Fehling attributes the disease to a pathological increase in the 
activity of the ovaries, in consequence of which there is a reflex 
action exerting itself upon the vaso-dilators of the blood-vessels of 
the bones. As the result of this there is hyperemia, under the 
influence of which an absorption of bony tissue takes place. This 
view is based upon the fact that a marked improvement of the dis- 
ease has followed removal of the ovaries. Fehling regards osteo- 
malacia, therefore, as a reflex tropho-neurosis of the osseous system 
proceeding from the ovaries. Winckel and others who have had 
experience in ovariotomy for osteomalacia do not accept this view. 

The sympto7ns of the disease begin usually after confinement. 
The patient complains of acute pain in the pelvis and in the lum- 
bar region, with radiating pains down the thighs and up the back. 
They are more severe at night, and continue throughout the prog- 
ress of the disease. The morbid change almost always begins in 
the iliac bone in puerperal cases. Pressure or movement seems to 
aggravate the pain, which is brought on by the weight borne upon 



DISEASES OF HONE. 6oi 

the pelvis when in the sitting posture. As the disease spreads and 
involves the spine and the inferior extremities, standing and walk- 
ing become painful. The deformity of the bones now becomes 
apparent. If the spine curves forward, there is lordosis; if the 
curve is backward, there is kyphosis, and with this malformation 
the ribs are often pressed in upon the spine. There may also be 
lateral curvature, or scoliosis. The vertebrae are compressed by 
pressure against one another, and the stature of the patient is in 
this way often materially diminished. The deformity of the pelvis 
consists principally in an approximation of the acetabula. The 
promontory of the sacrum and the symphysis pubis are brought 
close to each other. In the long bones fracture often occurs. 

The deformity of the pelvis is so great that in subsequent 
confinements, notwithstanding the softening of the bones, normal 
delivery "cannot take place, and ovariotomy or Caesarian section 
must be performed. In the extremities the softening of the bones 
permits of their being twisted about in every direction. If 
respiration is not interfered with, the internal organs usually 
perform their functions well. In severe forms of the disease there 
may be bronchial catarrh and diarrhoea with cachexia. In some 
cases there is often a spasmodic action of the muscles, and some- 
times convulsions. Fever is not present at first, but in the later 
stages a hectic fever may establish itself in case of inflammatory 
complications. A remission of the symptoms often occurs after 
recovery from a confinement, but with the return of pregnancy the 
disease reappears. The intellect does not seem to suffer. 

The section of bone shown in Figures 83 and 84 was taken from a case 
of spontaneous fracture of the left femur. The patient, a native of Ire- 
land and twenty-two years of age, was confined twenty-two months before, 
being delivered of a seven-months' child. Since then she had suffered from 
stiffness of knee and pains in the thigh of the left limb, and also in the right 
limb. The record of the case does not state the cause of fracture, which was 
at the junction of the upper and middle thirds of the femur. The bone fail- 
ing to unite and there being suspicion of malignant disease, the thigh was 
amputated. The next day a fracture of the right thigh was discovered, 
which united without delay, but six months later the patient was still 
unable to stand upon it. 

The prognosis of the disease appears to be extremely unfavor- 
able, particularly in its puerperal form. Of 87 such cases reported 
"by Lietzmann, 60 died, although it should be said that a majority 
of these cases died of complications occurring during confinement. 
The duration of the disease may, however, be long, varying all 
the way from two to ten years. The prognosis is somewhat more 



602 SURGICAL PATHOLOGY AND THERAPEUTICS. 

favorable in non-puerperal cases. In its early stages the disease 
may be mistaken for rheumatism or for syphilis, owing to the 
peculiar osteocopic pains. With the appearance of deformities in 
the bones or of fracture there is usually little doubt as to the 
diagnosis, although it may be supposed that some of the bony 
displacements are caused by the presence of malignant disease. 

In the treatment of osteomalacia there appears to be no thera- 
peutic agent which seems to exert a beneficial effect upon the 
condition of the bones. The remedy which has most often been 
used — namely, the phosphate or carbonate of lime — is thought by- 
some to be worthless and to throw additional work upon the 
kidneys; but the fact remains that there is an unusual drain upon 
the system of these chemical substances, and an artificial supply 
may at least tend to restore the desired equilibrium. The employ- 
ment of food rich in lime-salts, such as vegetables, fish, and meat, 
and porter, is recommended. Careful attention to the diet is 
probably the most important requirement in the management of 
the case. Cod-liver oil (with or without phosphorus) and iron are 
tonics frequently recommended for this affection. They have no 
specific action upon the processes going on in the bone, but they 
serve the purpose of maintaining the patient's strength, and thus 
placing the system in a condition more favorable for reparative 
processes. Women should be warned of the dangers of a second 
pregnancy. 

Recently ovariotomy has been performed for this affection. In 
the early Porro operations, which were performed on women with 
rachitic pelves, it was found that a rapid improvement of the 
disease followed the operation. It occurred to Fehling, therefore, 
to try the effect of the removal of the ovaries. Winckel proposed 
that the operation should be limited to such cases where all other 
methods had failed and the patients had already had many 
children. The first operation of this kind was performed in 1887, 
and since that time 41 cases have been operated upon, with 
5 deaths, or a mortality of 12 per cent. Of these cases, 2 died of 
sepsis and 1 of fatty degeneration of the heart. 

A marked improvement was observed very soon after the 
operation, but it was not always permanent. The pains in the 
bones, particularly in the pelvis and thighs, were greatly relieved. 
The ability to walk came more slowly. In the majority of the 
cases there was permanent cure. In the case of pregnancy Porro' s 
operation — or, as a substitute, Caesarian section combined with 
ovariotomy — may be performed. In the great majority of cases 



DISEASES OF BONE. 603 

Potto's operation (removal of the uterus and ovaries) is the one 
which should undoubtedly be chosen. 

2. Rickets. 

Rachitis, or rickets (/>«^c, a spine), is a disease of infancy and 
childhood characterized by a disturbance of nutrition and an irreg- 
ular development of bone, causing a change in its composition, 
texture, and form. 

The period of life at which this disease is most commonly seen 
is in the first and second years. In a series of cases compiled by 
Bradford and Lovett, 710 occurred in the first year, 831 in the 
second year, 232 in the third year, 50 in the fourth year, 27 in the 
fifth year, and after that period 26 cases only. It seldom begins 
before six months or after three years. Rickets is occasionally 
seen in individuals at the age of puberty, although the affection at 
this period is rare. 

It is an old theory that rickets is due to an abnormal develop- 
ment of acids. Heitzmann suggested that it may be due to the 
presence of lactic acid. This acid is supposed to be formed in the 
body as the result of digestive disturbances, acting as an irritant on 
the bone-forming tissues and causing solution and excretion of 
lime-salts. According to other authorities, the absence of lime is 
explained by its insufficient administration in food. Kassowitz 
called attention to the great vascularity of the medullary tissues in 
rachitic bones, and he sought in this condition of the bone an 
explanation of the disease, which he assumed was due to inflam- 
matory hyperaemia of the osteogenic tissues. 

Pommer, seeing the early and frequent disturbances in the motor 
system in this disease and the frequent complications of the nervous 
system, advanced the theory that the disease has its origin in the 
central nervous system. According to Monti, the cause of rickets 
lies in a defective nutrition of the affected children. All forms of 
nutriment which cause dyspepsia, and consequently makssimila- 
tion, or which do not contain the proper nutritive elements, bring 
on rachitis. The artificial feeding of children with patent foods 
has been thought to be a fertile source of the disease. In menage- 
ries, where animals live under highly artificial conditions, rickets 
is often seen. 

Any disease or condition of life which favors debility in an 
infant serves as a predisposing cause. Bad hygienic surround- 
ings, damp dwellings, crowded tenements, and poor ventilation are 
conditions under which the disease seems to thrive. Acute febrile 



604 SURGICAL PATHOLOGY AND THERAPEUTICS. 

diseases, such as pneumonia, scarlet fever, and measles, are frequent 
forerunners of rickets. Rickets is not so distinctly an inherited 
disease as one resulting from an enfeebled condition of the parents 
engendered by constitutional affections, such as syphilis or tubercu- 
losis, or as the result of poverty. 

Rickets is common in Northern and Middle Europe, and especi- 
ally in England. In America the disease is neither very prevalent 
nor severe, and, except in negroes, Italians, and Portuguese, very 
great deformity is rare (Bradford). According to Stedman, it is 
much less common among the children of Irish parents, but 
negroes are, almost without exception, rachitic. The disposition 
in the colored race seems to be an acquired one, for it is said that 
native Africans seldom, if ever, show any evidence of the disease. 

Rickets may develop during intra-uterine life (foetal rickets), or 
it may begin then and develop fully after birth (congenital rickets). 

The principal pathological change is seen at the epiphyseal lines 
of long bones and beneath the periosteum. It consists apparently 
in an insufficient supply of lime-salts to the bone, and is character- 
ized by an extensive absorption of bony tissue and the formation 
of bone without lime-salts, or the so-called u osteoid tissue." 

A description of the normal ossification of long bones at the 
epiphyseal line serves to make clearer the peculiar changes seen in 
rickets. Near the line where cartilage and bone come in contact 
are seen the cartilage-cells beginning to increase in numbers, and 
as this line is approached they are arranged in columns. Arriving 
close to the line, these columns are found to contain cartilage-cells 
closely packed together and much increased in size. These changes 
are characteristic of active growth in the cartilage. At the line of 
junction with the bone it is found that the further growth of the 
cartilage is arrested by the deposition of a narrow layer of lime- 
salts. Directly below this calcified layer is the medullary tissue of 
the bone, with its loops of blood-vessels pushing up against the 
calcified zone, which it presently absorbs. The cartilage-cells 
lose themselves in the advancing medullary tissue, some of them 
probably becoming marrow-cells. As these finger-like processes 
of vascular tissue push their way up into the cartilage, the tra- 
becular of cartilage left between them are partly absorbed, and 
partly changed into bone through the agency of osteoblasts which 
form around them. 

The most marked divergence from this process in rickets is the 
absence of the calcification-line which is so constant and so charac- 
teristic a feature of the normal growth of bone. In severe forms 



DISEASES OF BONE. 605 

it is wanting entirely; in moderate rickets traces of it may be found 
here and there. The next most important change — and one that 
never fails — is the increase in size of the zone of active cartilage- 
cell growth. The columns of crowded cartilage-cells extend over 
a much greater area than normally. The third important change 
is the formation of the most irregular and enlarged and highly- 
vascular medullary spaces, which grow up into the cartilage in the 
most tortuous shapes (Ziegler). The white line of calcification 
between cartilage and bone is therefore wanting; the growing 
cartilage forms a very broad transparent layer, and the boundary- 
line between cartilage and bone is most irregular. Patches of car- 
tilage are consequently seen still unaltered much below the upper 
edge of the bony tissue. The rest of the cartilage, as it is gradually 
enveloped by the vascular medullary tissue, changes into osteoid 
tissue. A zone of osteoid tissue — that is, bone which has not yet 
become calcified — is formed beneath the cartilage. This zone is 
consequently more or less soft and yielding, and it has a tendency 
to bend under pressure. 

These osteoid trabecular have no regular form or arrangement 
like the normal bony trabecular. Still lower down are found lime- 
salts deposited in the central axes of these trabecular, and in this 
way a layer of partially ossified substance is formed. In the peri- 
osteal layer of growing bone spongy bone-tissue forms, partly by 
the absorption of old bone and partly by the formation of osteoid 
tissue, so that when the disease is well advanced the surface of 
bones is covered with a highly vascular tissue which offers resist- 
ance to firm pressure, but which can easily be cut with a knife. 

While in this stage of the disease the condition of the bone 
resembles strongly that seen in osteomalacia; the difference lies in 
the process. The layer of bone which has no lime-salts in it is, in 
the case of osteomalacia, decalcified bone; in rickets it is newly- 
formed osteoid tissue. The bone which contains lime-salts is in 
osteomalacia always old bone; in rickets it is partly old and partly 
newly-formed bone (Ziegler). 

As a result of the disturbance of the process of ossification 
there is thickening of the ends of the bones, caused by a growth 
of epiphyseal cartilage. The periosteal growth of uncalcified 
osteophytes causes a thickening of the shafts of long bones and of 
the outer table of flat bones. When a cure finally takes place the 
bones appear unusually thick and heavy. The bones often fail to 
attain their full growth, owing to this disturbance at the growing 
point, and as a result of the yielding nature of the new tissue they 



6o6 



SURGICAL PATHOLOGY AND THERAPEUTICS. 



are unfit to perform their functions properly, and they become 
bent by pressure or twisted out of shape by muscular action. If 
the periosteum of a long bone is the principal seat of the disease, 
the shaft of the bone becomes curved; if, however, the disturbance 
is greater in the epiphyseal line, there will be a crook at the end 
of the bone when pressure is brought to bear upon it. In conse- 
quence of these changes in the skeleton the subjects of rickets 

become not only deformed, but are 
often greatly stunted in their growth 
(Kg- 85). 

The accompanying illustration (Fig. 85) 
is from a drawing of the skeleton of an 
Indian, twenty-one years of age, one of 
the Six Nations. His mode of locomotion 
was by a large wooden bowl in which he 
sat, and moved forward by advancing first 
one side of the bowl and then the other by 
means of his hands. The nodules or ''ad- 
ventitious joints" were "the result of im- 
perfect ossification, or, in other words, of 
motion before ossification was completed." 

The principal deformity of the head 
appears to consist in an enlargement of 
its transverse diameter, and there is a 
great prominence of the frontal and pa- 
rietal bones. The head has the appear- 
ance of being unusally large, but care- 
ful measurements seem to show that this 
is due partly to its shape and partly to 
the imperfect development of other re- 
gions of the body. The fontanel les 
remain open an unusual length of 
time, and the parietal and occipital 
bones are often soft and yielding, 
giving to the touch a parchment-like 
sensation, due to the absorption of 
bone at certain points, while at others 
it remains very porous. This con- 
dition is known as craniotabes. The 
sutures also remain broad and soft and membranous. The bones 
of the face appear to be impeded in their growth, and they give, 
therefore, to the skull an appearance of unusual size. Dentition 
is in consequence retarded, and the teeth show an unusual tendency 




Fig. 85. — Extreme Deformity of 
Skeleton due to Rickets, showing 
enlargement of the ends of the 
bones (Sp. 1545, Warren Museum). 



DISEASES OF HONE. 607 

to caries. The upper incisors considerably overhang the lower. 
The very profound disturbance of nutrition which permeates the 
entire system is shown particularly in the changes found in the 
brain, which is often enlarged. More frequently, however, there 
is effusion into the ventricles, and as the result of this there 
is occasionally hydrocephalus as a complication of the disease. 
As a rule, these effusions come slowly, and they may eventually 
be absorbed. If they occur rapidly, they are often accompanied 
by convulsions, which may terminate fatally. 

The earliest change seen in the thorax is a slight swelling of 
the sternal ends of the ribs or at the line between cartilage and 
bone. This row of protuberances, which is very characteristic of 
the disease, has often been called the "rachitic rosary." These 
swellings are caused partly by the growth between cartilage and 
bone and partly by periosteal growth. Deformities of the thorax 
are due to the pressure of the atmosphere on the thorax-wall, and 
to muscular action, and to the impairment of growth of the ribs. 
The circumference of the chest is small, and there is a sinking in 
of the ribs in respiration at the point of insertion of the dia- 
phragm. Gradually the whole side of the chest becomes flattened. 
In this way the so-called "pigeon-breasted" deformity is pro- 
duced. The clavicles are usually bent forward in a sharp curve, 
and the scapulae may also be more or less distorted. The spinal 
column may be curved backward. Kyphosis is a very common 
deformity in this disease. Scoliosis and lordosis are also not 
unfrequently seen. The pelvis in moderately severe rickets is 
somewhat flattened; the sacrum sinks deeply into it, and the lower 
portion of the bone is bent sharply forward. The iliac bones are 
small and flaring. 

If the pelvic bones are excessively softened, the promontory of 
the sacrum protrudes, the region of the acetabulum is pressed 
inward, and the symphysis becomes prominent, the deformity 
somewhat resembling that seen in osteomalacia. 

Epiphyseal swellings are seen at the wrist- and ankle-joints, 
and in severe cases at the ends of the phalanges of the fingers 
and the toes. Where the shaft of the long bone is profoundly 
affected, not only deformity, but even fracture, may occur. The 
humerus and the femur appear to be the bones most liable to break 
under these circumstances. 

In the graver forms of the disease there is usually a prodromal 
stage, during which a change seems to have taken place in the 
child's character. It no longer seems disposed to walk, and may 



608 SURGICAL PATHOLOGY AND THERAPEUTICS. 

not even be willing to leave its bed. Its temperament becomes 
irritable, and there is a great restlessness at night, with a tendency 
to throw off the bed-clothes. Some children have a tendency to 
bore their heads into their pillows, so that the scalp is often 
deprived of its hair. The appetite is capricious, and diarrhoea is 
not an infrequent accompaniment of an outbreak of the disease. 
There is loss of strength, and the skin becomes pale and is often 
bathed with perspiration, particularly about the head. A more or 
less well-marked febrile disturbance accompanies these symptoms, 
which may continue for two or three months. 

When the changes in the bones have developed the appearance 
of the child is strikingly characteristic. The patient is diminutive 
for its age. The head is apparently large, the face small and 
pinched. The expression is intelligent, and the child is preco- 
cious rather than backward in its mental development. The 
muscles are soft and flabby, but there is no actual impairment 
of their movements. Although there is no genuine paralysis, 
reflex nervous disturbances are not uncommon. There is often 
great hyperesthesia of the skin. Colicky pains in the abdomen are 
explained in this way, as are also attacks of laryngeal spasm, which 
is apt to accompany the hydrocephalic condition or inflammation 
of the air-passages. 

The parts of the skeleton most likely to be affected first are the 
bones of the wrist and the ends of the ribs. Kyphosis is also a 
most common deformity, the curve being most frequent at the 
juncture of the dorsal and lumbar regions. The articulations are 
in general more or less relaxed. Later the other osseous deform- 
ities already mentioned occur. 

In the lighter forms of the disease the constitutional disturbance 
may be very slight. Beyond a tendency to diarrhoea there may 
have been no disturbance whatever, and the first evidence of any 
disease may be the deformity in bone. In some cases the children 
appear to be in robust health. The disease in the bone may in this 
case be well marked: there may be found swelling of the ankles, 
the wrists, and the knees, and curved spine, narrow chest, and 
protuberant belly when the lower extremities are affected. The 
child assumes the rachitic attitude on standing. The thighs are 
straddled, the knees bent, the shoulders thrown back, and the belly 
prominent. 

The disease is usually very slow in its progress, and it may last 
one or two years. In America the prognosis is rarely grave. In 
the severe cases death rarely occurs as a direct consequence of the 



DISEASES OF 'BONE. 609 

disease, but rather as a result of the enfeebled condition combined 
with some complication. When the deformities are well marked 
they may remain permanently in a certain degree. Sometimes a 
spontaneous straightening- of a curved limb may take place. Spon- 
taneous arrest of the disease mav occur at any staee. 

The most effective prophylactic treatment consists in the proper 
feeding of children. The child should be kept at the breast as long 
as possible during the first year of its life. If the disease comes on 
during the nursing period, it may be necessary to resort to bottle- 
feeding or to careful attention to the condition of the mother's 
milk. In artificial feeding the rules of sterilization of food should 
be adhered to strictly if it is possible to carry them out. After six 
months the child may be given meat-juice or raw beef in small 
quantities. 

Baths and friction of the skin have often a beneficial effect upon 
the circulation, and they are strongly recommended by Monti. 

Cod-liver oil may be given in small doses even during the first 
year of life. Stimulants in small doses are also well borne in the 
very young, and they take the place of a tonic. Iron may be given 
to older children. The tincture of eucalyptus globulus in doses of 
from 10 to 40 minims, three or four times a day, is recommended 
by Stedman. The compound syrup of the hypophosphites and the 
syrup of the lactophosphate of lime are remedies which are fre- 
quently given. 

Kassowitz, whose theory of the disease has already been referred 
to, recommends very small doses of phosphorus, and he regards 
this drug almost as a specific for the disease. He bases his view 
upon an experimental study of its effects upon animals. The dis- 
ease being due, in his opinion, to an increased vascular action 
of the bone-forming tissues, he finds that phosphorus produces a 
decrease of vascularity and prevents an absorption of bone. Small 
doses of phosphorus were found by him to check the softening of 
the bone in a comparatively short time. These views are not, 
however, shared by other writers who have tried this drug. Brad- 
ford and Lovett find the syrup of the iodide of iron the most useful 
of the many drugs advocated in rickets. 

3. Osteoporosis. 

Osteoporosis, senile atrophy, and fragilitas ossium or osteo- 
psathyrosis (<fydd-opo<;, fragile) are terms which denote closely-allied 
conditions of the bone. This change in the bone differs from that 
of rickets or that of osteomalacia in that there is simply an absorp- 
39 



6io SURGICAL PATHOLOGY AND THERAPEUTICS. 

tion of bone without the accompanying pathological change. It 
is effected by what is known as lacunar absorption. At the point 
where the absorption is to take place are found many nucleated 
cells or the so-called " osteoclasts," which appear to bring about a 
solution of the bony substance. They lie in an indentation in the 
bone called " Howship's lacunae." These cells are quite numerous 
when absorption is taking place on a large scale, and they appear 
to eat into and give a rough appearance to the edge of the tra- 
becular. In this way the medullary spaces become much enlarged, 
and the bone thus becomes more porous; hence the name osteo- 
porosis. The medullary tissue loses its cells and appears to consist 
almost entirely of fatty tissue. This change may take place in 
advanced years in that condition known as senile atrophy. The 
change is seen in its most typical form in the flat bones, such as 
the bones of the cranium, the scapula, and the pelvis, and in those 
portions, more particularly, not covered by muscles. In the 
parietal bones the process may be so extensive as to cause destruc- 
tion of the outer table and the diploe, and even of a portion of the 
inner table. Cases are reported where at certain points the entire 
thickness of the bone has been absorbed. The occipital bone is 
affected next in frequency, and lastly the frontal bone. Irregular 
depressions are formed on the surface of the skull by the unequal 
absorption at different points. There is also a formation of new 
bone to a certain extent, showing an effort at repair. Thus it may 
come about that there is a thickening in the diploe, and bony de- 
posit may also be found on the inner surface of the cranial vault. 
The bones of the face may undergo a marked senile atrophy, and 
the alveolar processes may entirely disappear. In the spine and 
the bones of the extremities there is more or less absorption in the 
interior of the bone, the trabecular being much thinned and here 
and there being entirely absorbed. If a large portion of bony tissue 
thus disappears, the outer bone may sink in at this spot. If there 
is much external absorption, the bones become smaller, and this 
occurs oftenest at the articular extremities of the long bones. 

When the absorption has reached a point where the strength of 
the bone has seriously been impaired, there is presented the con- 
dition known as fragilitas ossium (Ziegler). 

There is seen in new-born infants a form of this fragility which 
appears to be due, according to Klebs, to disappearance or to imper- 
fect development of the bone-forming cartilage. A section of the 
bone through the line of ossification shows the zone of growing 
cartilage to be very narrow. The bony trabecular growing up from 



DISEASES OF BONE. 611 

beneath are very thin, and they contain only a few bone-corpuscles. 
Cross-sections in the shaft of the bone show that the medullary 
tissue has very few cells and has undergone gelatinous degenera- 
tion, and that the bony trabecular are permeated with an anasto- 
mosing network of canals in which here and there lie bone- 
corpnscles. 

The movements of the foetus when the bones are in this con- 
dition may be sufficient to produce numerous fractures, and in this 
way so many fractures may take place that the bones may exten- 
sively be comminuted. This atrophy of bone is often seen in the 
insane. 

Among the symptoms of this affection are mentioned vague 
pains in the bones simulating rheumatism. There may be no sign 
whatever of the disease until a bone breaks suddenly from slight 
injury, as from muscular action. Lathrop reports the case of a 
woman eighty-two years of age who sustained a fracture of the 
right femur while she was standing at a bureau. For some time 
previous to the accident she had suffered severe pain at the point 
at which the fracture occurred. 

Murray reports a case of a girl who sustained in all forty frac- 
tures. Many of the cases reported are, however, probably due to 
rickets or to osteomalacia. The main point of distinction between 
fragilitas ossium and these diseases is the brittleness of the bone, 
whereas in rachitis and osteomalacia, the lime-salts being largely 
absent, there is a tendency of the bones to bend rather than to 
break. 

A frequent cause for lacunar absorption is the inactivity of the 
bone, which occurs when a limb or a part has been rendered useless 
and is unable to perform its functions. Thus the process is found 
going on in the bones of the stump of amputated limbs. In frac- 
tures that have healed with much displacement the overlapping 
ends become atrophied, and the trabecular in the interior of the 
bone, which played a part in supporting the weight of the body, 
disappear. 

Neuro-paralytic atrophy of bone near the joints, or arthropathy, 
is caused by an absorption of bone associated with disease of the 
central nervous system. The absorption of bone is very extensive 
in such cases, and joints may thus become disorganized. 

Atrophy may occur from pressure: this is seen in the bodies of 
the vertebrae which stand in the way of the expansion of an 
aneurism. A bone which becomes infiltrated by a malignant 
growth shows well the process of lacunar absorption. Here is 



612 SURGICAL PATHOLOGY AND THERAPEUTICS. 

seen the wormeaten-looking edge of the bone surrounding the dis- 
ease lined with a single layer of osteoclasts (Ziegler). 

4. Hyperplasia of Bone. 

The formation of new bone occurs usually as the result of 
chronic inflammation. If the bone increases uniformly in size 
in all directions, the change is called "hyperostosis." If the 
bone becomes thicker and denser, the condition is described as 
"osteosclerosis." The growth of new bone may take place in 
the form of endochondral ossification — that is, at the junction of 
cartilage with bone — and in this case an increase in the length of 
the bone occurs. An increase in thickness is due to the periosteal 
.growth of bone, and an increase in density is due to the apposition 
of new bone to the trabecular of spongy bone, and to consequent 
narrowing of the Haversian canals and the medullary spaces. 

Among the most striking forms of this hypertrophy of bone 
are those whose etiology appears to be more or less obscure. The 
peculiarly deforming enlargements of the bones of the head and 
face were described as early as 1697 by Malphigi as " cranio- 
scleroses." One of the most striking cases of this sort was re- 
ported in 1734 by Forcade. This surgeon had a son who was 
perfectly well until he had an attack of small-pox. As a sequel 
of this disease he suffered from a lachrymal abscess which sup- 
purated for a long time. As a result of this abscess a growth 
about the size of an almond formed in the nasal process, which 
growth gradually increased until it obstructed the nasal passages 
and afterward extended to the upper jaw, the lower jaw, and the 
zygoma, involving the orbits with the exception of the cranial 
walls. Extensive exostoses formed on the bones at various points. 
The eyes were pushed out of their sockets and speech became dif- 
ficult. The disease lasted over thirty years. At the autopsy the 
bones of the cranium were found to be much thickened and denser 
than normal. 

Virchow has given to this affection the very appropriate name 
leontiasis ossium. Baumgarten and Millat independently made a 
study of leontiasis ossium, and they agree in regarding it as a dis- 
ease distinct from all other types of bone-hypertrophy, such as 
acromegaly or ostitis deformans or the diffuse hyperostosis of 
syphilis. The disease begins in youth in healthy persons of 
both sexes; it is painless, and it starts most frequently in one 
zygoma. It consists in a growth, mostly symmetrical, of all 
or of several of the bones of the cranium and the face. The 



DISEASES OF BONE. 613 

bony growth is at first porous, but later is sclerosed. The 
cranium is increased to several times its normal weight and 
it becomes extremely hard. The disease brings about the most 
frightful deformity. Smell and sight gradually disappear, the 
eyes protrude, death finally occurring with symptoms of brain- 
pressure. The disease may last over thirty years, the other bones 
being unaffected. Virchow and Fischer report cases of hyper- 
ostosis of the sphenoid bone, and Virchow reports also cases of 
excessive bony growth of the frontal and parietal bones. 

In some forms of the disease that have been operated upon it is 
a question whether sarcoma was not a complication. Such opera- 
tions as have been performed give no permanent relief, and there 
appears to be no remedy for the disease. 

Gruber describes a case which is interesting, as it suggests a 
possible connection between the growth of bone and erysipelas, 
a disease associated with those hypertrophies of the connective tis- 
sue seen in elephantiasis. A girl ten years of age suffered from an 
epileptic seizure, followed by pain in the head and delirium lasting 
for several months. An attack of erysipelas followed one of the 
convulsions. In her sixteenth year she lost her hearing and her 
head began to increase in size, the growth being accompanied by 
severe pain. She died a year later of a second attack of erysipelas. 
Virchow also quotes a case in which a thickening of the cranial 
bones w T as accompanied by an enlargement of the bones of the 
trunk and the lower extremities. 

An example of this kind is described by Paget, who gave the 
name ostitis deformans to the disease. He first saw the case in 
1856. The patient, a country gentleman forty-six years of age, 
had always enjoyed good health when, without assignable cause, 
he began to be subject to aching pains in the thighs and legs. 
The bones of the left leg began to increase in size, and a year or 
two later the left femur also enlarged considerably. These changes 
were followed, during a period of nearly twenty years, by a growth 
of other bones. The spine became curved and rigid and the head 
increased 5^ inches in circumference. The bones of the face were 
not affected. The patient, when standing, had a peculiar bowed 
condition of the legs, with marked flexure at the knees. He 
finally died of osteosarcoma, which originated in the left radius. 
Paget collected eight cases, and it is interesting to note that in 
five of them death occurred from malignant disease. 

The bones in the case just described were found after death to 
be very much thickened, and drawings of the femur and cranium 



614 



SURGICAL PATHOLOGY AND THERAPEUTICS. 



show a marked osteosclerosis. In some cases of craniosclerosis 
the bone may become as dense as ivory. The appearance of this 
condition is shown in Fig. 86 (taken from a specimen in the War- 
ren Museum), the history of which specimen is unknown. 




^*f^ 



Fig. 86. — Calvarium of a case of Ostitis Deformans (Specimen 1209, Warren Museum), 



Taylor of New York reports a typical case of ostitis deformans, 
the patient being a Canadian. Cases have also been reported in 
the United States by McPhedran, McKenzie, and Gibney. 

The bones most frequently affected are the tibia, the femur, the 
clavicle, the spine, and the cranium. There is no tendency to 
symmetry in the disease. According to Taylor, there appears to 
be a mixture of rarefying ostitis (osteoporosis) and formative ostitis 
(osteosclerosis). The femur and the tibia not only become thick- 
ened, but also become bowed under the pressure of the weight of 
the body, and the trochanters rise above Nelaton's line. The 
joints are not affected. 

In forty-three cases analyzed by Thieberge, twenty-one were 
men and twenty-two were women. The disease appeared usually 



DISEASES OF BONE. 615 

after forty. There was no history of heredity, syphilis, rheuma- 
tism, gout, or tubercuk- 

Acromegaly may be distinguished from ostitis deformans, as it 
is limited chiefly to hypertrophy of the hands, the feet, and the 
face. The spinal column is frequently enlarged, and there may be 
marked kyphosis. The head may also be enlarged, but the long 
bones of the extremities remain unaffected. In cretinism — for 
which it might be mistaken — the bones, as a rule, are shorter 
than normal, although the cranial and some of the other bones 
may become enlarged or thickened. In acromegaly there is true 
hypertrophy of the bone, and the disease begins at about the 
twenty-fifth year. There is a rapid pulse, and a tendency to pal- 
pitation and moderate muscular atrophy. 

The so-called " giant growth of bones, M or gigantism, is often 
congenital in character and is entirely unaccompanied with any 
inflammatory symptoms. It is often observed to develop after 
menstrual disturbances. A marked change takes place in the 
affected portion soon after birth. In one case reported by Fischer 
the amputation of an enlarged finger was followed by increase in 
size of the entire limb. The hyperostosis of the bones of these 
giant limbs is well marked, but there is nothing in their anatom- 
ical structure to suggest the presence of an inflammatory process. 
The disease differs from ostitis deformans in that the growth of bone 
is accompanied by equal hypertrophy of the surrounding parts. 

Some writers believe that acromegaly arises in connection with 
disturbances of the pituitary body of the thymus gland. It is possi- 
ble that both this disease and the giant growth may be connected 
in some way with disturbance of the nerve-centres. According to 
Putnam, acromegaly may be benefited by the employment of the 
thyroid juice or powder. 

Fischer shows that an in crease in the length of bone may even 
follow slight injuries. He reports the case of a boy twelve years 
of age who was run over by a wagon, causing a contusion of the 
bones of the right leg. In the course of a year this leg became 4^- 
cm. longer than the other, and the bones were also much thicker 
than normal. Taylor reports the case of a lady who fell, injuring 
the thigh without fracture. A gradual enlargement, with an out- 
ward curving of the bone, has since taken place. Fischer reports 
several cases of abnormal growth of the bone following necrosis. 
A case of shortening of 3^ cm. after fracture was reduced to a 
shortening of 1 cm. by compensatory growth. Elongation of the 
bone is also mentioned as the result of inflammation of the joint. 



616 SURGICAL PATHOLOGY AND THERAPEUTICS. 

In those cases in which there has been no suppuration the growth 
progresses slowly and suppuration never takes place. Where no 
distinct inflammatory process has preceded this growth it has been 
suggested that a chemical substance may be the cause of this change 
of nutrition. Ziegler calls attention to experiments which have 
been made by giving small doses of phosphorus and arsenic during 
the period of bone-growth, after which evidences of an increased 
formation of bone were found at the points of physiological 
activity. 

The pathological changes seen in the marrow of boiies de- 
serve mention here. The marrow of children is bright red in 
color, which is caused by the presence of cells and blood-vessels. 
The stroma of this tissue is made up of a delicate network of 
branching cells, and the walls of the vessels to which its pro- 
longations are attached are very thin. The cells supported in 
this reticulum are round, and they contain a bright nucleus and a 
nucleolus, some of the cells being vacuolated. They vary greatly 
in size. There are also cells containing eosinophile-granules, 
others containing fat-granules, nucleated and non-nucleated red 
blood-corpuscles, and pigment-cells, and also single and many- 
nucleated giant-cells. This tissue is supposed to play a part in 
the development of the blood, and it is probable that red blood- 
corpuscles are formed in it. These cells gradually disappear with 
increasing age in the long bones, and the stellate cells which 
form the reticulum change by the absorption of fat into fat- 
cells. After the age of from fourteen to sixteen years the marrow 
of the long bones consists principally of fatty tissue. In the flat 
bones the marrow retains its red lymphoid character. According 
to Tizzoni, the fatty marrow changes back to red marrow after extir- 
pation of the spleen (Ziegler). 

In old age the number of cells in the marrow decrease, and in 
their place a mucous fluid is found. The marrow appears to under- 
go a sort of gelatinous degeneration both at this period of life and 
in many chronic diseases. The amount of fat-marrow may occa- 
sionally greatly be increased. In many cases when the fat is 
absorbed lymphoid cells take its place. This condition is occa- 
sionally seen in leucocythaemia, in cancerous cachexia, and in 
chronic suppuration in bone. When the bone is injured hemor- 
rhages often take place in the delicate vascular structure, particu- 
larly in the marrow of young individuals. This blood may be 
absorbed, leaving behind it pigment, or it may become the start- 
ing-point, when infected with pyogenic cocci, of osteomyelitis. 



DISEASES OF BONE. 617 

5. Phosphorus Necrosis. 

Necrosis of the jaw, as the result of phosphorus-poisoning, was 
first noticed in 1838, soon after the introduction of the manufacture 
of phosphorus matches in factories. Of late years, owing to the 
introduction of the proper precautions in their manufacture, the 
disease has become much less common. This disease occurs almost 
exclusively among the operatives in match-factories. The chem- 
ical composition employed consists of phosphorus and chlorate of 
potassium, with particles of ground flint to assist friction, a color- 
ing agent, and the best quality of Irish glue. The tipping of the 
match-sticks is accomplished by dipping their ends in a warm solu- 
tion of the composition placed in hollow pans and maintained at 
the proper temperature by a steam-bath. From these dipping-pans 
fumes constantly rise into the faces of the workmen and dippers. 
Both in cutting the sticks and in packing the matches their hands, 
coming in contact with phosphorus, are sufficiently coated with 
the composition to appear luminous in the dark. 

The regions chiefly affected are the jaw-bones, but the inflam- 
mation may spread to the adjoining bones and involve the vomer, 
the zygoma, the body of the sphenoid bone, and the basilar process 
of the occipital bone. How the phosphorus-fumes act upon the 
bones has been a subject of much discussion. By some it has been 
supposed that the arsenic which is often found with the phosphorus 
was the cause of the inflammation. Wegner has shown by experi- 
ment that the disease may be produced by the direct action of the 
phosphorus-fumes upon those portions of the bone on which the 
periosteum was exposed by dissecting ofT the mucous membrane. 
In confirmation of this view is cited the fact that those individuals 
who suffer from carious teeth are most liable to the disease. It is 
supposed that the fumes enter the carious cavity and reach the 
peridental membrane by way of the apical foramen (Potter). 

According to Hirt, operatives with diseased teeth are affected 
three times as often as those with healthy teeth. Such individuals, 
therefore, are carefully excluded from some factories in America. 
It has been maintained, however, that the local inflammation is 
due to a general poisoning of the system, and the advocates of 
this theory point to the fact that many operatives work for several 
years in factories before being affected. Hutchinson mentions a 
case where the prolonged use of phosphorus internally led to typi- 
cal necrosis of the jaw. Weak, anaemic, and tuberculous individ- 
uals are much more liable to be affected than are robust persons. 



618 SURGICAL PATHOLOGY AND THERAPEUTICS. 

According to Mears, the statements made in regard to the intro- 
duction of the poison through carious teeth should be received 
with some modification. He saw numbers of operatives suffering 
from carious teeth who worked for years in match-factories without 
symptoms of poisoning. In all the cases of poisoning seen by him 
there was an accumulation of tartar around the necks of the teeth. 
In his opinion there is a chronic toxic condition of the system 
with local irritation of the gums, which may be aggravated by 
decayed teeth or by tartar. Under the influence of some exciting 
cause — as a cold — an inflammation may begin and extend to the 
periosteum. In many of the operatives complaining of ill-health 
from the fumes of phosphorus he noted hemorrhagic transudations 
from the gums. He believes that the poison is introduced into the 
system partly by inhalation and partly by being swallowed with 
the food, and that the toxic condition precedes the disease of the 
jaw. In some individuals these toxic symptoms are so acute, 
accompanied by nausea, vomiting, etc., that they are compelled to 
abandon work. 

The inflammation begins probably in the peridental membrane, 
and spreads easily to the periosteum, with which it is continuous, 
and from this point works its way along, by a slowly-creeping 
inflammatory process, until a large portion of the covering of the 
bone may be involved. 

The disease begins as an inflammation of the gum, accom- 
panied by toothache. On removing the tooth a certain amount 
of pus is discharged from the alveolus and the inflammation 
extends to the alveolar process. One by one the teeth are lost in 
this way until the entire alveolar process may be denuded of its 
periosteum. A foul pus, with often an odor of phosphorus, is 
discharged from beneath the edges of the mucous membrane into 
the mouth. Meanwhile the external soft parts become reddened 
and very much swollen and indurated, causing much deformity 
and presenting to the touch the sensation as if an extensive and a 
very thick involucrum was forming. Dissection shows, according 
to Markoe, that new bone is not formed at so early a period. Pus 
may be discharged externally through several openings. In the 
interior of the mouth the swelling may so extend as to involve the 
tongue. By this time the whole bone becomes involved in the 
inflammatory process, and there occurs osteomyelitis as well as 
periostitis, with the inevitable result of necrosis. When the 
periosteum first becomes inflamed new bone is formed here and 
there on its inner layer, and after suppuration has separated it 



DISEASES OF BONE. 619 

from the bone, these bony masses may remain adherent to the 
periosteum and form new bone, or they may be broken down and 
discharged. The most extensive bone-formation is found at those 
points where the periosteum has remained longest in contact with 
the bone, this being at its inferior border (Busch). In very acute 
cases when the periosteum is separated quickly there is a very 
small amount of new bone formed. The sequestrum can usually 
be removed through the mouth, as the alveolar portion of the bone 
is the part first exposed. 

The progress of the disease is rarely so extensive on the upper 
jaw, as the free drainage of pus prevents the same amount of 
burrowing that occurs in the lower jaw. The upper maxilla is 
affected somewhat less frequently than the lower. 

In consequence of exposure of the sequestrum to the cavity of 
the mouth the pus with which it is surrounded is mixed with 
saliva and undergoes decomposition, and the discharge from the 
mouth is sometimes of the foulest description. A portion of this 
material is inevitably swallowed, and accordingly the health and 
digestion of the patient suffer. The progress of the disease is 
slow, and toward the end the general health may greatly be 
impaired. 

With the removal of the sequestrum suppuration soon ceases 
and cicatrization takes place. In the majority of cases a cure is 
finally obtained, but when the inflammation once begins it cannot 
be arrested until it has produced extensive destruction of bone. 
In those cases that terminate fatally death may occur from an 
extension of the process, in the way already mentioned, to the 
base of the brain, and from meningitis. The long-continued 
suppuration may lead to amyloid degeneration of the internal 
organs. In a certain number of cases pulmonary consumption 
may become a complication of the disease. 

Much can be done in the way of prophylactic treatment by 
proper ventilation of factories. In some factories exhaust fans are 
so arranged as to remove the fumes promptly from over the dip- 
ping-machines. Careful washing of the hands before eating is a 
rule that should always be laid down. Individuals with carious 
teeth or in feeble health should not be accepted as operatives. 
According to Busch, the employment of white phosphorus should 
be abandoned, and amorphous red phosphorus, such as is used in 
the preparation of Swedish matches, should be substituted. The 
chief objection to this change is said to be the expense. Mears 
recommends the use of turpentine inhalations, basing his views 



620 SURGICAL PATHOLOGY AND THERAPEUTICS. 

upon the power of the vapor of turpentine to neutralize that of 
phosphorus. In many factories the operatives are in the habit 
of carrying wide-mouthed bottles containing turpentine, suspended 
by straps around the neck. In the early stages of the disease the 
condition of the teeth and gums should carefully be attended to, 
and any tendency to suppuration should be arrested by the use 
of gargles containing boracic acid, phenyl, myrrh, or alcohol. A 
weak solution of permanganate of potash may also be used to 
advantage. 

When suppurative periostitis is established every effort should 
be made to limit the extent of the suppuration as much as pos- 
sible. The periosteum should freely be incised and thorough 
drainage be given to the pus. The sinuses should be syringed out 
with a weak solution of carbolic acid or of corrosive sublimate, 
and the strength of the patient should carefully be maintained. 
There is little hope of preventing necrosis when once this stage of 
the disease is reached. 

The question as to when the diseased bone should be removed 
is one about which many operators differ. The general weight of 
opinion at the present time is to wait until the sequestrum has 
separated, and until the new bone formed by the periosteum is 
sufficiently strong to preserve the shape of the original bone. 
The sequestrum should be removed through the mouth, as it is 
here freely exposed, and the deformity of the external incision 
will thus be avoided. Care should be taken to disengage the 
laminae of new bone from the sequestrum, so as to injure them as 
little as possible during the operation of removal. After removing 
the dead bone the cavity may be dressed by a packing of iodoform 
gauze. 

6. Arthritis Deformans. 

Arthritis deformans is a chronic inflammation of the joint in 
which not only the joint-capsule, but also the bone, is affected in a 
way which may cause great deformity, but the function of the joint 
is more or less preserved. Many joints may simultaneously be 
affected. 

The disease has received a variety of names, which fact alone 
seems to indicate that the pathology of the affection has not been 
understood. These names are — chronic rheumatic arthritis, rheu- 
matic gout, arthrite sesche, etc. 

The etiology of this affection is obscure. It may occur in young 
people, but it is oftener seen in those past middle life. In aged 
people it is often accompanied by other senile affections, such as 



D/SEASES OF BONE. 



621 



atheroma and ossification of tendons or of muscles. In some cases 
there appears to be a distinctly traumatic origin, as the disease is 
seen to follow injuries or fractures which involve the joint. Such 
conditions are not infrequently seen in the knee and the elbow, and 
occasionally also in the hips. 

It may occur spontaneously in almost any of the joints, although it 
is most frequently seen in the finger-joints and the hip, but it is seen 
also in the shoulder and in the vertebrae. It occurs in all sorts and 
conditions of life and in all countries. There are few families in 
which there is not some aged member more or less afflicted with 
this frequent accompaniment of old age. Men are somewhat less 
liable to it than women. 

There are two principal forms of this form of joint-inflamma- 
tion — the mono-articular and the poly -articular. The former is 
found principally in the knee- and hip-joints (malum coxse senile). 
The latter occurs in several joints at a time, attacking the fingers 
and toes, principally in women. 

One of the most striking features of this affection is the change 
which takes place in the cartilage. This change consists in a break- 
ing up of the surface of the carti- 
lage into fine filaments, owing to » 
the absorption of the cement-sub- 
stance which holds the fibrillar to- 
gether. In a cross-section of car- 
tilage undergoing this change there 
is seen an anastomosing system of 
lines and clefts, in some of which 
are seen cartilage-cells either in a 
state of proliferation or of degen- 
eration. In a vertical section the 
cells in the deeper layers of the 
are seen in active pro- 
This cell-growth may 
be sufficient to produce thickening, 
and even nodules of cartilage, at cer- 
tain points. In the deeper layers 
are also seen nodules of softening, 
and at other points is seen a growth 
of blood-vessels which have pushed their way up from the marrow 
of the bone. In this way the cartilage gradually becomes softened 
down, and is worn away by the friction of the articular surfaces, 
and the surface of the bone thus becomes exposed. At other points 



cartilage 
liferation 




Fig. 87. — Arthritis deformans, 



ith 



Eburnation of Bone due to Absorp- 
tion of Cartilage. 



622 SURGICAL PATHOLOGY AND THERAPEUTICS. 

the bone undergoes the change which has already been studied as 
osteosclerosis. It becomes dense and receives, through friction, an 
ivory polish or eburnation (Fig. 87). In the poly-articular form 
there is often a pannus-like growth of the synovial membrane over 
the cartilage. This membrane becomes rich in cells and blood- 
vessels pushing their way into the cartilage, which softens and 
breaks down before this growth. Deep depressions are thus formed 
which subsequently run together. In such cartilage very large 
stellate cells with extensive proliferation are seen occupying large 
cavities in the bone, the exact nature of which cells is not clear. 
By some they are supposed to be chondroclasts (Weichselbaum). 
This growth of the synovial membrane may sometimes extend to 
the opposite side of the joint, and adhesions may be formed in this 
way. 

In the bone changes of different kinds are going on. On the 
exposed surfaces is the eburnation already alluded to, and around 
the edges of the joint is exuberant hyperostosis, by means of which 
new formation of bone takes place, giving a peculiar shape to the 
articular end of the bone. In the interior the spongy bone under- 
goes absorption. Many of the trabecular disappear. There is rare- 
fying ostitis which results in osteoporosis. As the result of these 
several changes the head of the bone appears as if it had at one 
time been composed of a substance capable of softening from heat, 
and while in that condition had been held carelessly while it was 
allowed to cool. The neck of the femur is bent at a sharper angle 
to the shaft. Around the head of the femur a deep fringe of bone 
overhangs the neck. The head of the bone is much enlarged or it 
is partially absorbed. The "molten" fringes of bone are seen at 
the knee- and elbow-joints : they overhang the bodies of the verte- 
brae and often weld them to one another. 

It should not be understood that the bone at any time is softer 
to the touch than the normal bone. On the contrary, the bone on 
the surface usually appears dense and even highly polished. Mean- 
while, the tissue of the synovial membrane has been growing 
steadily. There is an increased production of connective tissue 
and blood-vessels, and frequently there is an excessive growth of 
adipose tissue. The capsular ligament and the synovial membrane 
become in this way much thickened. The folds of the joint and 
the villi become enlarged, and they grow into the articular cavity. 
These villi may become very numerous, and a joint thus changed 
may appear, when opened, to be lined with a furry membrane. 
Sometimes these elongated tufts may attain an unusual size, and 



DISEASES OF BONE. 623 

occasionally they consist principally of adipose tissue, and the 
name lipoma arborescens has been given to these tumor-like 
formations. According to Sokoloff, these growths are due to the 
existence of a negative pressure in certain portions of the capsule, 
and are an indication that that portion of the joint in which they 
are found has been deprived of its function. At the point of the 
insertion of the capsule into the bone there may be bony growths 
of this shape which may become partially separated and attached 
only by a loose pedicle. Many of these outgrowths may finally 
become separated, and may collect in large numbers in the interior 
of the joint. 

As a rule, there is no effusion of the joint-serum. Probably the 
function of the synovial membrane is materially altered, so that it 
produces less of its natural secretion. These chronic inflammations 
are therefore characterized by an unusual dryness of the articular 
surface. Hence the name "chronic dry arthritis." 

The medullary tissue may undergo considerable degeneration, 
and may change to a gelatinous tissue, which may soften down, 
when extensive, and give rise to the formation of cysts. A 
lymphoid tissue may form in other cases. 

The earliest symptom perceived by the patient is the presence in 
one of the joints of a certain amount of stiffness, which is increased 
with rest and disappears somewhat with exercise. Gradually the 
joint — as, for instance, the knee — becomes somewhat enlarged. 
This, however, is no symptom of inflammation, and on examina- 
tion the increased size is seen to be due to an enlargement of the 
ends of the bones, and not to an effusion into the joint. Occa- 
sional attacks of pain, which are mistaken for rheumatism, are fol- 
lowed by increased loss of function, and this condition may be 
maintained without much change through a long series of years. 
The limb becomes considerably crippled, and the patient is obliged 
finally to use a cane or a crutch. This impairment of function is 
due to weakness of the muscles with partial stiffness of the joint, 
so that the limb cannot fully be straightened. The general health 
of the patient, however, is good. 

The poly-articular form occurs usually in younger subjects. 
The joints, the hands, and the feet may suffer, as well as the larger 
joints. There are frequent exacerbations of inflammations after 
catching cold, at which time the joints become stiffer. Motion is 
also impaired by muscular contraction, so that certain limbs event- 
ually become quite helpless. The deformity of the joint is not 
only great, but the bones are displaced upon one another by the 



624 SURGICAL PATHOLOGY AND THERAPEUTICS. 

contraction which takes place, so that in some cases complete dis- 
location may result. The general health remains good through 
a series of years, but in the most aggravated forms of the disease 
there may be great emaciation and enervation of the system, and 
the patient may succumb to some intercurrent acute disease. The 
disease in itself, however, is not fatal. 

The diagnosis of arthritis deformans can be made partly from 
the history of the case, which will enable the surgeon to exclude 
gout or rheumatism, and partly from the local examination of the 
joint. The absence of fluctuation will also exclude dropsy of the 
joint. Old dislocations caused by the affection may be difficult to 
recognize from traumatic dislocation. 

The ti-eatment of this disease is usually most unsatisfactory, and 
patients are apt to wander from one physician to another and from 
one watering-place to another in search of a panacea. A great 
deal may be accomplished by an intelligent person in the manage- 
ment of his daily life, so that all disturbing influences may be 
reduced to a minimum. Iodide of potassium, the alkalies, and 
other rheumatic remedies should faithfully be tried. The use of 
hot baths at certain watering-places at the appropriate season, if 
carried out systematically at intervals during a series of years, may 
prevent the increase of the disease. Delicate patients should, how- 
ever, resort to this treatment only under the most favorable condi- 
tions. Massage is a mode of treatment that will probably give 
more relief than any other. 

7. Spinal Arthropathy. 

Very extensive organic changes are found in the joints of indi- 
viduals affected with disease of the spinal cord. Among those dis- 
eases may be mentioned tabes dorsalis, myelitis, laceration of the 
cord, and degeneration due to compression. These changes are 
also seen after nerve-section (Ziegler). The joints most frequently 
affected are the knee, the hip, the shoulder, and the elbow. The 
wrist and the joints of the fingers and toes are less frequently affected. 
Inflammatory thickening and ulceration are seen in the synovial 
membrane. Effusion takes place at the joint,- and there is a swell- 
ing of the periarticular tissues. In the severest forms of the dis- 
ease the capsule is entirely destroyed, and the ends of the bones 
undergo degenerative and formative changes. The articular end 
of the bone is absorbed, and a shapeless mass of bony nodules is 
left upon the end of the shaft of the bone. Suppuration only 
takes place in case the joint has been subjected to injury. 



DISEASES OF BONE. 625 

With the destruction of the articular ends of the bone disloca- 
tion usually takes place. The disease, which is supposed to be 
caused by an injury to the trophic nerves, is classed by many as 
tropho-neurosis. The origin of the disease has had but little light 
thrown upon it. The process is a chronic one, but it is frequently 
followed by a disability of the joint. 

Excision has been performed successfully on one or two occa- 
sions, but it is probable that such treatment is indicated only in 
exceptional cases. 

8. Ankylosis. 

Ankylosis is usually divided into two varieties — trite and false. 
True ankylosis formerly meant complete bony union of the two 
bones forming the joint, and it was confined to that variety. False 
ankylosis was a term used to denote stiffness of the joint due to 
contraction of the structures external to the joint, which prevented 
motion. Many waiters reject the term "false ankylosis," and use 
the word "contractions" instead. The word "ankylosis" is T 
however, so extensively used to denote a stiff joint that it does 
not seem advisable to discard ' ' false ankylosis. ' ' True ankylosis 
should, however, be used to denote the firm adhesion of one bone to 
another, whether it be by bone, cartilage, or by connective tissue. 

The causes which bring about this variety of ankylosis are of 
an inflammatory character. Among these causes may be mentioned 
suppurative synovitis, trauma, particularly fracture into the joint, 
and inflammation due to adjacent disease of the bone, as tubercu- 
losis or primary tuberculosis of the joint, etc. The histological 
changes that occur consist in the formation of granulation tissue, 
which may develop from the synovial capsule in a pannus-like 
growth over the cartilage, and become adherent to it. The car- 
tilage at the same time becomes degenerated, and it is converted 
into a soft mucous tissue into which the connective tissue forces its 
way. Later the cartilage itself is changed into connective tissue. 
The granulation tissue also attacks the cartilage of the opposing 
bone in a similar way; consequently fibrous ankylosis takes place. 
Such a fibrous growth may consist merely of a few bands adhering 
to opposing cartilage, the rest of the joint remaining unchanged, 
or it may involve the entire articular surface, which is thus ob- 
literated. The cartilage may be penetrated from below by the 
tissue growing from the medullary canals of the bone, and granu- 
lation tissue may work its way into the joint through this route: 
When the mass of tissue lying between the ends of the bones is 

40 



626 



SURGICAL PATHOLOGY AND THERAPEUTICS. 



mainly cartilage, only a small portion consisting of connective 
tissue, there occurs cartilaginous ankylosis. 

If the cartilage has been destroyed entirely by the growth from 
the capsule and the bone, the granulation tissue intervening 
between the bones may ossify and produce a bony ankylosis 
(Fig. 88). In some joints may be found a combination of fibrous, 




Fig. 



-Ankylosis of the Hip-joint (Sp. 1421, Warren Museum). 



cartilaginous, and bony union. In some cases the bony union is 
so complete that anatomical outlines are obliterated, and there is a 
continuous mass of spongy bone where the joint formerly existed. 
False ankylosis is due principally to conditions which exist in the 
capsule of the joint or to the parts external to the articulation. It 
is this form of ankylosis which is principally seen after fractures. 
The chief cause of joint-stiffness under these circumstances is, 
according to Bruns, cicatricial contraction of the muscles in con- 
sequence of injury received at the time of the fracture or from 



DISEASES OF BONE. 627 

the shortening due to rest in the relaxed position. Contractions 
of the ligaments and fasciae around the joints may occur in a simi- 
lar manner. Menzel showed experimentally that the contraction 
of the fasciae occurred quite early. Having placed the hind leg of 
a rabbit in a plaster bandage for eleven days, he found the stiffness 
of the knee-joint was immediately relieved by a division of the 
fascia lata. Adhesion of the tendons in their sheaths may also 
impair the motions of the joint. The stiffness and serous effu- 
sion which are found in joints near, and even at some distance 
from, fractures is almost a universal occurrence. Reyher sought to 
discover the cause of these pathological changes by experiments 
on animals. 

Reyher experimented upon dogs with plaster bandages, keeping the joints 
confined during periods varying from ten to three hundred and forty-three 
days. Until sixty-two daj-s had elapsed he found no change in the joint. 
After that time the first changes noticed were a shortening of the ligaments 
and of the capsule at those points that were approximated during the enforced 
rest. Later the capsule was found considerate thickened by fusion with the 
indurated tissue which surrounded it. The synovial membrane, however, 
remained normal. There was no sign of inflammation. In joints that had 
remained immobilized for a year those portions of the joint-cartilages which 
were actually in contact remained unchanged, while the portions that were 
not in contact had undergone degenerative changes. It was thus apparent 
that those portions of the joint which remained functionless during this 
period underwent fatty degeneration. 

It is evident that we have here to deal w 7 ith a degenerative rather 
than an inflammatory change. The joint has grown smaller, so as 
to accommodate itself to its restricted function. This does not 
account for the inflammatory changes, such as effusion and ten- 
derness, which are seen in joints soon after using them for the 
first time. This point was also tested experimentally by Reyher. 

Stiff bandages were applied on dogs for different periods of time, and 
after removing the bandages and applying passive motion the joints w T ere 
opened and examined. In those joints which had been in the plaster for a 
few days no change was found. After an interval of thirty days there was 
discoloration of the synovial fluid and infiltration of the periarticular tissue. 
After one hundred and thirty-three days there was bloody effusion into the 
joint, eccyhmosis in the membrane, and rupture of adhesions. 

These experiments show that true inflammatory changes follow 
the breaking up of the adhesion in the capsule, in consequence of 
which there is synovitis such as is ordinarily caused by a sprain. 
In the case of joints which lie close to the point of fracture there 
are signs of primary inflammation, which are often obscured by 
the principal injury. The joint may have been sprained at the 



628 SURGICAL PATHOLOGY AND THERAPEUTICS. 

time of the fracture, or the inflammatory process around the frac- 
ture may extend to and involve the joint. In such cases there 
may arise inflammatory changes inside the joint and conditions 
which may favor true ankylosis. 

A knowledge of these various causes which produce stiffness in 
the joints will enable the surgeon to deal more intelligently with 
individual cases. In the use of passive motion care must be taken 
to confine it to those cases where inflammation does not exist, and 
to begin the movements so quietly as to cause as small amount of 
injury to contracted tissue as possible. Massage plays an import- 
ant role in these conditions, enabling one to produce absorption 
of infiltration into the periarticular tissues, and thus to soften the 
part before violence is applied to it. 

Where an articulation has been obliterated by a growth of 
whatever kind, and more or less of the cartilage is destroyed, the 
chances of restoring mobility by breaking up the adhesions 
between the bones are, as can readily be seen, exceedingly small. 

When bony ankylosis has taken place resection of the joint may 
be performed in the upper extremity for the purpose of restoring 
motion. In the lower extremity this operation can only be 
employed for the purpose of straightening out a crooked limb. 

9. Periostitis. 

The periosteum is so intimately connected with bone that a con- 
sideration of this tissue as a separate organ is hardly advisable, and 
the behavior of periosteum in diseases of bone has already been 
referred to on several occasions in this book. There are, how- 
ever, one or two affections of this structure which it is perhaps 
better to consider by themselves. In studying disease of the peri- 
osteum it is well to remember that this tissue is not only com- 
posed of the dense membrane which the dissector finds so difficult 
to remove from the bone, but also of an outer layer composed of 
connective tissue containing here and there a few fat-cells. 

The inner layer is chiefly made up of fine elastic fibres forming 
a dense membranous network. In early life the periosteum is quite 
vascular, and is intimately connected with the epiphyseal cartilage, 
but much more loosely with the shaft of the bone. The blood-ves- 
sels contained in the periosteum make their way, usually at a right 
angle with the axis of the shaft, into the cortical bone, which is 
therefore to a certain extent dependent upon the periosteum for its 
nourishment. In case of extensive injury to this membrane the 
blood-supply may suddenly be cut off and necrosis or exfoliation of 



DISEASES OF BONE. 629 

the bone may take place. The thickened periosteum which is 
found in cases of chronic periostitis is the result of an inflamma- 
tion of the outer layer, chiefly of the periosteum. 

Acute periostitis, particularly that form which terminates in 
suppuration, is usually secondary to some form of infective disease 
of the bone, such as osteomyelitis. It may also occur as one of the 
sequelae of typhoid fever, scarlet fever, or measles. The non-sup- 
purative acute type may be the result of trauma, and it is found 
principally upon the superficial bones, as the tibia. 

The symptoms of an acute periostitis are those of a superficial 
swelling upon the bone, which is not thickened or enlarged. The 
swelling is exceedingly tender, the slightest pressure causing acute 
pain. The presence of pus is manifest by the redness of the skin 
and fluctuation in the centre of the inflamed mass. An incision 
will be followed by a flow of pus, and the appearance of the sur- 
face of the bone shows that that tissue has also been involved in 
the process, and is probably the primary seat of the inflammation. 
Usually the superficial forms of suppurative periostitis are not very 
extensive. The secondary suppurative periostitis which accompa- 
nies septic bone-inflammation may involve the greater portion of 
the shaft of the bone. 

Many of the smaller subperiosteal abscesses are not due simply 
to the ordinary pyogenic cocci, but other organisms, whose pyo- 
genic qualities are now recognized, are occasionally found. Park 
calls attention to a number of instances in which the typhoid 
bacilli have been found in periosteal inflammation, whether sup- 
purative or non-suppurative, and he mentions a case in his prac- 
tice of a boy who suffered a most intense and painful multiple 
periostitis during the end of the third week of an ordinary attack 
of enteric fever. Doubtless many such forms of periosteal infection 
are seen in other forms of infectious disease. 

The chronic form of suppurative periostitis has already been 
described in connection with tubercular disease of the bone. It is 
rare to find a chronic suppuration of the periosteum which has not 
emanated from the bone beneath. In feeble and aged individuals 
an inflammation of the periosteum, due perhaps to a blow, may 
finally terminate in the formation of pus. Such abscess may con- 
tain either pyogenic or tubercular organisms. In some cases of 
inflammation of the periosteum of long bones, chiefly in young 
persons fifteen to twenty years of age, the solid constituents of the 
pus are comparatively few in number. Under these circumstances 
the contents of the abscess appear to consist chiefly of a mucous 



630 SURGICAL PATHOLOGY AND THERAPEUTICS. 

or synovial fluid. Such cases usually run their course without 
febrile disturbance. This form of periostitis has been regarded by 
Poncet and others of the French school as a type of inflammation 
which has not reached suppuration, but has formed an exudation 
rich in albumin. An attempt has been made to separate this 
variety as a special type of periosteal disease under the name 
periostitis albuminosa. It is not, however, recognized by Yolk- 
mann and others of his school. Vollert suggests that there may be 
a peculiar condition of the effused serum in which the pus-cor- 
puscles are suspended, which causes the protoplasm to undergo a 
mucous degeneration, and thus brings about a destruction of the 
cells. 

Chronic nonsuppurative periostitis may occur as the result of 
injury, and a most obstinate and painful affection may be developed 
in this way. The result of such a form of periosteal inflammation 
is to produce not only a thickening of the periosteum, but also a 
formation of new bone, the result of the increased activity of the 
osteogenetic layers of the periosteum. The new bone forms very 
much in the same way as is observed in the development of callus. 
The bone appears much thickened at this point when examined at 
the bedside. A section through the bone, however, shows the shaft 
still well defined and of normal thickness, the new growth having 
formed entirely upon the surface of the bone. The bony trabecular 
forming around the blood-vessels and extending from the perios- 
teum to the cortical bone run at right angles to those of the shaft 
of the bone, and the two layers are thus easily distinguished from 
each other. 

It is this form of periostitis which is so often seen in the sec- 
ondary stage of syphilis. In this disease enlargements may make 
their appearance upon the superficial bones, accompanied with 
symptoms of chronic inflammation. In addition to the new bone 
which is formed beneath the periosteum, there is a formation of 
bone around the trabecular of the old bone, in consequence of 
which a sclerosis or eburnation of the bone may take place. This 
osteosclerosis may eventually involve the whole thickness of the 
shaft of the bone, and the marrow may disappear. As this process 
may go on in different parts of the bone at the same time, great 
irregularities in the contour may result, and the surface appears 
very uneven. Such bones when macerated are very characteris- 
tic of syphilis. Occasionally the superficial bone-formation may 
amount to a growth of considerable size, resembling an exostosis. 
These bony growths are occasionally seen on the inner surface of 



DISEASES OF BONE. 631 

the calvaritim. Accompanying these bone-formations there is more 
or less pain, particularly at night, known as nocturnal and osteo- 
copic pain. 

In addition to the osteoplastic form of periostitis, there may be 
in syphilis suppurative periostitis. The swelling on the surface 
of the bone may become discolored and softened, and an incision 
will give vent to a small amount of thin pus. At the bottom of 
the pus-cavity the bone will be found eroded or carious, and a con- 
siderable amount of soft granulation tissue is seen in the interstices 
of the exposed bone. Surrounding the bone-ulceration there is at 
the same time a bone-formation, and after the abscess has healed a 
depressed cicatrix with a raised margin marks the site of the inflam- 
matory process. If the suppuration is more extensive, there may 
be a destruction of a considerable portion of the bone beneath, and 
a sequestrum which has formed may eventually be removed from 
the bottom of the sinuses. Such sequestra are occasionally seen in 
the later stages of syphilis on the frontal bone. 

Occasionally a prominent swelling may form on the surface of 
the bone, which swelling is at first hard, but later becomes soft, 
and when opened discharges a thick, clear fluid. The swelling, 
if thoroughly laid open, is found to consist of a soft and gelatinous 
tissue the result of degenerative changes. These gummata are 
found on the bones of the skull and the tibia, on the hard palate, 
and indeed on almost all other portions of the skeleton. 

The destruction of bone produced by these forms of syphilitic 
inflammation may at times be quite extensive, and may be mis- 
taken for tubercular or ordinary suppurative periostitis or osteo- 
myelitis. 

The treatment of periostitis in its chronic or non-suppurative 
form will depend somewhat upon the etiology of the particular 
case in hand. In the chronic non-suppurative forms, which are 
the commonest, the patient usually seeks relief from pain, which is 
chiefly felt at night, but it may also occur during the daytime. In 
many cases absolute rest in the recumbent posture is sufficient to 
give relief to the pain. The symptom is apt to recur, however, 
when the patient begins to walk again. Counter-irritation with 
tincture of iodine, blisters, or even leeches, will often give great 
relief. In obstinate cases, when local applications have failed to 
relieve pain, an incision should be made through the periosteum to 
the bone. In the tibia, where periostitis is so obstinate and pain- 
ful, the incision should be vertical and of sufficient length to 
divide the thickened periosteum. The periosteum should then be 



632 SURGICAL PATHOLOGY AND THERAPEUTICS. 

slightly retracted, so as to relieve the pressure upon the bone, and 
the edges of the skin should be brought together so as to unite 
by first intention. In some cases it may be advisable to bore 
into the bone to determine the presence of an abscess. The sur- 
face of the bone should always be carefully inspected. In case of 
suppuration the surface of the pus-cavity should thoroughly be 
curetted, and the wound should be allowed to heal by granulation 
under a dressing of iodoform or aseptic gauze. In case of deep- 
seated suppuration in the bone with necrosis the abscess-cavity 
should be laid open thoroughly when the sequestrum has loosened, 
and the dead bone should be removed. The same radical measure 
should be adopted in the syphilitic cases of suppurative periostitis 
and ostitis that has already been laid down in the chapter on Os- 
teomyelitis, and the internal administration of iodide of potassium, 
with or without mercury, should not be neglected. Many cases of 
chronic suppurative periostitis of syphilitic origin will heal rapidly 
without operation under specific treatment. 



XXVIII. TUMORS. 

The word u tumor" is used freely by surgeons and pathologists 
to describe all kinds of swellings, but in its more limited signif- 
icance it is applied to a certain well-defined group of pathological 
growths. A tumor may be defined as a malformation, non-inflam- 
matory in character, existing as a more or less independent struc- 
ture, not fulfilling any physiological purpose. 

It was not until Virchow published in 1863 his work on 
tumors that there had been any scientific classification. Previous 
to that time all was confusion, and but few partially successful 
attempts had been made to substitute a more orderly arrangement. 
Many of the old names in use at that time show that surgeons 
were content to base their classification on the outward appearance 
or on the consistency of tumors. Some of these names, such as 
"fungus haematodes," etc., are unknown to the present genera- 
tion, but such terms as "polyp" and " scirrhus " and "cauli- 
flower" are legacies to which many still cling, and "sarcoma," 
still in good standing, was first used to indicate the fleshy appear- 
ance of certain growths. 

Abernethy, however, during the latter part of the eighteenth 
century called attention to the resemblance which certain tumors 
had to certain tissues of the body. 

There existed, however, among the laity, as well as among the 
profession at this time, a firm belief that tumors were a sort of 
parasite attached to and growing in the body. Many tumors were 
in fact classified as "entozoa." It was supposed that tumors were 
composed of structures essentially different from those which are 
found in the body, and that an independent circulation was 
formed in them, as in the embryo of the chick, and later a 
communication was established between its own vascular system 
and that of the body. 

Bichat in attempting to divide tumors into two families — those 
which resembled anatomical structure and those which had a 
structure sui generis — showed himself to be influenced by the 
prevailing belief of the time. Lobstein introduced the words 
" homoeoplastic " and "heteroplastic" to indicate this difference 

6.33 



634 SURGICAL PATHOLOGY AND THERAPEUTICS. 

in growths. That he belonged to the school of humoral patholo- 
gists is shown by his assumption that tumors were formed from 
some sort of lymph. He recognized that the homceoplastic 
tumors were generally benign, and therefore he called the homceo- 
plastic lymph "euplastic;" the other form of lymph he called 
" kakoplastic, " to indicate that tumors formed from it were 
usually malignant in character. The latter class was supposed to 
develop from a dyscrasia w T hich produced a profound change in the 
blood, and it was therefore hoped that there could be extracted 
from it a chemical substance which would represent its malignant 
quality — a sort of carcinomatin (which, by the way, has reappeared 
lately under the name of cancroin), and which would serve as a 
means of diagnosis. Tumors of all kinds were subjected to 
chemical examinations, and these views affected even so recent a 
writer as Rokitansky. A feeling, however, existed at that time 
that a more exact classification of tumors was needed. Fleisch- 
mann in 1815 declared that tumors were copies of the normal 
organic parts of the body from which they grew. John C. 
Warren, writing in 1834 on tumors, proposed "to present the 
different tumors under the head of the different textures of the 
body, so far as may be done." It was but a short time after this 
that Johannes Miiller gave the law that " the tissue of which a 
tumor is composed has its type in the tissues of the animal body, 
either in the adult or in the embryonic condition." 

The attempt to find a specific chemical substance having failed, 
an effort was next made to discover a specific sarcoma- or cancer- 
cell, and the view prevailed (more particularly in France) that the 
spindle-cell described by Lebert was the specific element of cancer. 

It remained for Virchow to sweep away all theories about some- 
thing specific, something which did not already exist in the body. 
He demonstrated for all time that cells could not develop de novo 
in a blastema or fluid, and that the type which rules in the growth 
and development of the body ruled also in the development and 
growth of tumors. 

Tissues and cells may grow in parts of the body where they are 
not expected to be found, but they are always human cells and 
human tissue. It must not be expected to find plums or cherries, 
or even feathers, growing in the body, although hair and even teeth 
may be found growing where they do not belong. Virchow recog- 
nizes a homology and a heterology in tumor-growth, but not a 
heterology in the sense of Bichat. An isolated mass of epithelium 
growing in connective tissue or a cartilage-growth in the testicle 



TUMORS. 635 

are examples of heterology as found in the body of man. Tumors, 
however, cannot be classified under these two heads, for a certain 
growth may be homologous at one time and heterologous at an- 
other. As a rule, however, when a growth is found occurring in a 
tissue where it does not belong, it is probably malignant, and ho- 
mologous growths are, as a rule, benign. 

Of the various theories as to the origin of tumors, that of Cohn- 
heim has of late years attracted most attention. This theory seeks 
an explanation in abnormal conditions of the embryonic cells. 
According to this theory there must have been in the embryo 
during its development more cells produced at some point than are 
necessary for the development of that particular region. This 
excessive cell-production may have been distributed over one of the 
germinal layers or it may have been limited to some one spot. In 
the latter case a single organ might be the seat of a growth at 
some future time; in the former, the whole system might be in- 
volved, such as the skin, the adipose tissue, or the bones. In con- 
firmation of this theory Cohnheim quotes the experiments of Leo- 
pold, w T ho showed that when fragments of cartilage from a young 
rabbit were transplanted into the peritoneal cavity they were more 
or less completely absorbed, but that when foetal cartilage was used 
for transplantation there could be produced a considerable growth 
which might present the characteristics of an enchondroma. In- 
deed, Virchow called attention to fragments of cartilage in the shafts 
of bones near the epiphyseal line, which fragments might become 
the source of a tumor. 

The occurrence of that variety of tumor known as u teratoma," 
as well as of many other congenital forms of tumor, is in favor of 
this theory. The dermoid cysts of the orbit and the neck are the 
results of an incomplete obliteration of the branchial clefts. That 
a child of ordinary size should sometimes grow to be a giant, or 
that gigantism of an extremity should develop after birth, is a pos- 
sibility that can hardly be explained in any other way. 

The embryonic nature of the tissues of sarcoma suggests the 
origin of these tumors from such remains of foetal structure. The 
immediate cause of their growth, after a dormant period which may 
extend through the greater portion of life, is explained by Cohnheim 
as due to an increased blood-supply to the part. Physiologically, 
there is seen such an increased nutrition at different portions of the 
body at the age of puberty: with the development of the sexual 
organs there come a growth of hair and a change of features to 
those more closely resembling the parental type. At this time 



636 SURGICAL PATHOLOGY AND THERAPEUTICS. 

also the exostosis or the enchondrorna may appear near the epi- 
physeal cartilage, and congenital wens may be noticed for the first 
time. It is well known that ovarian cysts or tumors of the breast 
are stimulated to increased growth at the period of pregnancy. 
Multiple fibromata and lipomata may readily be explained by the 
abnormal condition of the embryonic cells of a considerable por- 
tion of a germinal layer. 

The growth of tumors in certain localities has been ascribed by 
Virchow to increased local irritation at those points. A familiar 
example is cancer of the lip, which has been supposed to be due to 
the use of the pipe. Cancers are frequently seen at other orifices, 
such as the pylorus, the os uteri, and the rectum. Cohnheim, how- 
ever, explains this peculiarity by the complicated arrangement at 
these points of the germinal structures, where folds of the germi- 
nal membranes occur or where the germinal membranes join. 

The hereditary predisposition to tumors is strongly marked in 
certain cases, and examples are not infrequent where cancer has 
apparently descended through several generations. In the family 
of a patient upon whom the writer operated for cancer of the breast 
there existed a marked hereditary predisposition. The maternal 
grandmother died of cancer of both breasts at the age of thirty ; a 
maternal aunt died of cancer of the breast; a cousin on the 
mother's side died of cancer of the rectum; and an aunt on the 
father's side was operated upon the year before for cancer of the 
breast. Such family tendencies have been recorded, but they are 
not sufficiently numerous to establish a law. In 102 cases, 10 only 
were found by Lebert to have had ancestors who suffered from 
cancer, and Eeroy d'Etiolles found only 1 such in 278 cases. A 
tendency to the development of malignant growths is supposed to 
consist in the inability of the surrounding tissue to resist. Thiersch 
seeks in this want of resistance in the connective tissue, brought 
about by age, an explanation of the growth of cancer at that period 
of life, the yielding tissue being unable to resist the growth of the 
epithelial structures. 

Examples of the growths of tumors following injury are quite 
numerous. A lady applied to the writer for an opinion upon a 
lump in her breast. Four weeks before she slipped and received 
a blow at the spot from a gas-fixture. The swelling and discolora- 
tion caused by the blow subsided, but an induration remained. 
Eight weeks later the entire organ was infiltrated with carcinoma. 
Statistics collected by Boll in Langenbeck's clinic show, however, 
that in only 14 per cent, of the cases was trauma given as the cause 



TUMORS. 637 

of carcinoma, and Wolff's series yielded only 12 per cent, due ap- 
parently to the same cause. 

Virchow divided tumors into three general groups : histoid 
growths, or those in which only one tissue is found, such as 
fibrous tissue, which is found in fibroma; organoid growths, or 
those which, like organs, are composed of a combination of 
tissues, such as epithelium and connective tissue, which, for 
example, are found in adenoma; teratoid growths, or those com- 
posed of one or more complex structures, such as hair, bone, and 
teeth, the commonest example of which is found in dermoid cysts 
of the ovary. 

The classification generally adopted at the present time agrees 
with that w r hich Virchow arranged on an anatomical basis. Several 
of the groups included by him in the family of tumors have been 
omitted by subsequent authors, such as the haematoma, the hy- 
groma, the retention-cysts, and granulation tumors (tubercle, etc.). 

Connective-tissue Group. 

Fibroma, Myxoma, Glioma, Lipoma, 

Osteoma, Enchondroma, Sarcoma. 

Group of Tissues of Higher Function. 
Myoma, Neuroma, Angioma, lymphangioma. 

Epithelial Group. 

Adenoma, Carcinoma, Endothelioma, 

Cystoma, Teratoma. 

Clinically, tumors may be divided into two principal families, 
the benign and the malignant growths. To the latter group 
belong carcinoma and sarcoma. A few of the other forms of 
tumors have occasionally malignant tendencies when departing 
from their usual type, but, as a rule, all other tumors may be 
regarded as benign. 



XXIX. CARCINOMA. 

Carcinoma may be defined as a tumor composed chiefly of 
epithelial cells, differing more or less in their type and arrange- 
ment from the normal epithelial structures and having a tendency 
to an unlimited growth. These cells grow into the surrounding 
connective tissue, which is thereby stimulated to increased devel- 
opment. Carcinoma is composed, therefore, of two distinct struc- 
tures — the epithelial cells and the vascular stroma. 

The epithelial cells, true so far to their type, lie in contact with 
one another, being more or less firmly united by a cement sub- 
stance, or sometimes they are apparently continuous with one 
another, and are not supplied with blood-vessels. The stroma 
containing the vascular supply is arranged with alveoli, in which 
lie the cancer-cells. The absence of a tissue intervening between 
the cells is characteristic of epithelium, and it constitutes a mark 
by which, in doubtful cases, cancer is distinguished from sarcoma. 
In alveolar sarcoma is presented an arrangement of the cells closely 
resembling cancer, but close inspection shows that a fine reticulum 
of connective tissue separates the sarcomatous cells from one an- 
other. 

Carcinoma (xapxlvoc;, a crab), or cancer, derives its name from 
the peculiar outward appearance which the disease has when infil- 
trating the skin, showing numerous prolongations, accompanied by 
hyperemia of the blood-vessels. The word "cancer" has been 
used both by the laity and the profession to mean any kind of 
malignant growth: for this reason some pathologists prefer to dis- 
card the term. Its derivation, however, is the same as carcinoma, 
and it should therefore be used to signify only malignant epithelial 
growths, and be synonymous with carcinoma. 

Cancer has its origin in the epithelial structure of the body 
only. Remak first formulated the law that the tissues of the 
embryo were developed from three germinal layers, and that the 
tissues of these layers were throughout life distinct from one 
another. This theory has not universally been accepted by 
pathologists, some of whom have thought that cancer might 
originate in connective-tissue structures. When it was discov- 
ered that cancer grew from endothelium as well as epithelium, 

638 



CARCINOMA. 639 

this was supposed to be an exception to the law, but now it is 
known that these two kinds of cells spring from the same embry- 
onic tissue. 

Many pathologists have cited instances where cancer appeared 
to spring from bone or muscle, but in such cases it has generally 
been found that the primary growth was exceedingly small and 
had been overlooked. 

The etiology of cancer, as has been seen, is still obscure, but a 
great deal of interest has been taken of late years in the question 
of the parasitic origin of this disease. The presence of bacteria 
in carcinomata has been noticed by numerous observers. Scheu- 
erlen reported in 1887 a cancer bacillus which had been obtained 
by culture. The bacilli were short, and were capable of develop- 
ing spores. These organisms, when inoculated into the mammary 
gland of bitches, produced tumors containing epithelial cells. 
KubasofF injected into and fed to animals a bacillus he obtained 
from cancer, and it produced nodules in the internal organs. It 
was not clear, however, that these growths were epithelial in 
structure. Verneuil found certain bacteria in the degenerating 
parts of cancer that he thought stimulated the growth of tumors 
by exciting them to increased cell-production. Streptococci have 
been found in metastatic growths of cancer, showing that bacteria 
can be carried through the circulation to tumors, where they can 
settle and grow. Various forms of bacteria have been observed 
from time to time in carcinoma by careful investigators. 

It is evident that these organisms form in cancer, and it is 
probable that they produce inflammations and necroses in the 
tumor, and in some cases, possibly, they have some connection 
with the cachexia, but no evidence has been adduced to induce 
the belief that they have any causal connection whatever with the 
tumor (Councilman). 

The presence of intracellular organisms of quite a different 
character from bacteria has created much more speculation during 
the last few years. 

Since the anatomical nature of cancer has been understood, it 
has been known that peculiar cell-like bodies are a characteristic 
feature of the disease. Some of these bodies are found in the 
so-called "epithelioma," and form the centre of cell-nests, and 
they were supposed to be cells undergoing degenerative changes, 
such as colloid degeneration or the horny change. In the alveoli 
of the more malignant forms of cancer cells apparently undergoing 
vacuolation are often seen. 



640 SURGICAL PATHOLOGY AND THERAPEUTICS. 

Virchow as early as 1861 did not accept these views, but he 
suggested the idea of an endogenous cell- formation, and he named 
some of these cells " physalides" (<puayM^ a bladder). Recently 
the view has been gaining ground, although it is still strongly 
disputed by many good observers, that these cells existing within 
the epithelial cells do not belong to the human organism, but 
that they are animal parasites of a very simple organization, 
consisting of a single cell and classified as one of the numerous 
forms of protozoa. 

A very brief account of the members of this family of the 
kingdom of the protozoa may here be given. The sporozoa were 
described by Balbiani as being composed of five different species 
of organisms — namely, gregarineum, coccidium, sarcosporidium, 
myxosporidium, and microsporidium. These parasites are widely 
distributed. They are found in all animals from man to the 
infusoria. Some of them give rise to epidemics of a grave 
character in animals, as the coccidium in the rabbit — quite a 
common disease in France, but rarely seen in America. The 
sarcosporidium gives rise to an epizootic disease in sheep, swine, 
and poultry. A number of fish annually die of disease produced 
by the presence of the myxosporidium, 1 and the microsporidium is 
the organism which caused such ravages among the silkworms of 
France, producing the maladie de la pebrine. 

The coccidium is the species said to be found in cancer, and is, 
therefore, of especial interest. This organism consists of a finely 
granular mass of protoplasm, with a nucleus not easily seen, and 
without an enveloping membrane during its period of growth, and 
in this period it inhabits an epithelial cell, where it becomes encysted. 
It finally breaks away from its host, and segmentation and sporula- 
tion take place. The spores may be voided from the intestine of 
an animal to enter that of another with the animal's food, and the 
cycle of development begins again. Sporulation may take place 
also inside the epithelial cell, as in the salamander, and during 
this process quite complicated structures form which it is hardly 
necessary to describe. The spores when freed enter a new cell, 
and thus multiply (Steinhaus). Balbiani was able to cultivate 
these organisms in water and in wet sand, and he was thus 
enabled to observe the changes which took place during sporula- 
tion. These organisms are very common in the livers of rabbits. 
Delapine found them in 92 per cent, of all rabbits examined. In 

1 Scott states that in American trout transplanted to New Zealand he has often found at 
the base of the tongue a tumor which proved on microscopic examination to be carcinoma. 



CARCINOMA. 641 

the livers of these animals they form tumors, which are cyst-like, 
and appear to consist of a dilatation of the bile-dncts. These 
tumors contain epithelial tissue which is described as adenomatous 
and papillomatous. These organisms are found in the new-formed 
epithelial cells, and also occasionally one, or more, is found in 
giant-cells. There is considerable infiltration of the surrounding 
tissue with granulation cells. 

That the pathogenic qualities of the sporozoa — or the u psoro- 
sperms," as French authors call them — are not confined to the lower 
animals has been recognized for many years. Gubler described as 
long ago as 1868 a tumor of the human liver that was supposed during 
life to be an hydatid cyst, but after death a large number of cancer- 
ous-looking tumors were found in the liver, one of them five inches in 
diameter. Within these tumors coccidia were found in or near the 
epithelium. There was very marked cachexia during life, as is so 
often seen in cancer. Podwyssozki found coccidia in cystic tumors 
of the bile-duct and in the liver-cells, causing irritation of the 
connective tissue and giving rise to icterus. He gave to them the 
name karyophagus hominis. They have also been found in the 
human intestine, accompanied by considerable destruction of the 
epithelium. They have been observed in cases where the epithe- 
lium does not appear to have been affected, as in pleuritic effusion 
and in the interstitial tissue of the kidney in a case of Bright' s 
disease. 

One of the first observations tending to associate these organ- 
isms with cancer was made upon a disease which was described 
simultaneously by Podwyssozki under the name of psorospermose 
folliculaire vegetante and by White as keratosis follicularis. 
Darier attributed the disease to the presence of organisms resem- 
bling coccidia. He next studied them with Wickham in a case of 
Paget' s disease of the nipple. In the mean time Thoma observed 
them in various forms of cancer. Darier describes them as enclosed 
in a hyaline membrane of double contour, from which they shrink 
when hardened in alcohol. These organisms as they grow push 
the nucleus into one corner of the cell which they occupy, so that 
it is often difficult to find the nucleus. Sometimes they are repre- 
sented as consuming the nucleus; sometimes enclosed in a mem- 
brane, and sometimes without one. Sjobring, who undertook to 
trace the cycle of development, followed them from the cells of a 
mammary cancer into the ducts of the gland, and finally he ob- 
served them in the stage of sporulation. 

Russell reported that these organisms could be particularly well 
41 



642 



SURGICAL PATHOLOGY AND THERAPEUTICS. 



Z 



brought out by fuchsin staining, but he regards these fuchsin 
bodies as being closely related to the yeasts; Woodhead, who also 
studied them with fuchsin, regards them as coccidia. He found 
them most numerous in rapidly-growing cancers and in secondary 
nodules, and Metschnikoff, whose training qualifies him for deter- 
mining the nature of such bodies, considers them parasites, prob- 
ably belonging to the order of coccidia. The number of observa- 
tions is now very great, and observers agree practically upon the 
morphology of these structures, such differences as are reported in 
description being probably due to accidents of growth in the tumor 
or to methods of preparation (Fig. 89). 

There are one or two suggestive points brought out in this con- 
nection by different observ- 
,/^llj: ers. Darier, in describing 

> ( g»\ these organisms in cancer 

43k J /~*% of the nipple, suggests that 
^^*%1 ^ e corpuscles may have 
XJ? .jJ become implanted between 
the papillae of the nipple 
during washing, as the coc- 
cidia live in water. The 
cultivation experiments of 
Balbiani in wet sand have 
already been alluded to. 
Haviland, who made a care- 
ful study of the geographi- 
cal distribution of cancer 
in England, found that the 
disease is most prevalent in 
marshy regions and in the 
wet soil of river-basins sub- 
ject to inundations. Wood- 
head points out that the 
conditions present in these 
localities are exactly those 
necessary for the development of psorosperms in rabbits — a disease 
which is most frequently met with among rabbits whose run is 
over marshy ground or over narrow areas where the drainage is 
imperfect. 

Observers are not unanimous, however, as to the parasitic nature 
of these organisms. Schutz thinks that most of the questionable 
intercellular structures found in carcinomata should be regarded as 









Fig. 89. — Cell-inclusions in Cancer of the Breast, 
the so-called "protozoa" (oc. 3, obj. -^ oil-im.). 



CARCINOMA. 643 

due to leucocytes which have become imbedded in the cell. Klebs, 



after careful study and experiment, decides that there are no posi- 
tive grounds for regarding these cells as parasites. He sees in the 
presence of these cells within the epithelial cells evidence ap- 
parently of the old French theory of the action de presence, the 
leucocytes exerting a fructifying influence upon the cancer-cells 
and causing them to multiply. Many still hold to the old idea that 
they are degenerated epithelial cells. All attempts to cultivate 
these cells from cancer- growth appear to have failed, and the num- 
ber of cases in which cancer has been inoculated successfully into 
animals is exceedingly limited. Hanau succeeded in transferring 
a typical epithelium from a rat to two other rats. He succeeded 
also in transplanting an epithelioma from one part of a man to 
another portion of his body, and in obtaining metastatic deposits 
around the implanted growth. Cancer has been transferred from 
one locality to another in the same individual in several other 
cases. Wehr also successfully transferred cancer from man to 
dogs. Hanau does not, however, regard his experiment as proof 
of the infectious nature of cancer. 

Councilman does not consider these structures parasitic, having 
seen them in many other morbid processes as well as in cancer. 
The parasitic origin he does not think has yet been proved, and on 
theoretical grounds it is hardly likely to be proved. Park, how- 
ever, sees in these investigations sufficient to encourage the hope 
that surgeons are on the eve of great discoveries which will settle 
the question of the origin of cancer. 

Cancer is said to be less common in tropical than in temperate 
climates. Haviland, as has been seen, proved the disease most 
prevalent in damp and in low-lying districts in England. It is 
said to be less frequently seen in Turkey, in Egypt, and in the West 
Indies, but this is doubted by Ziemssen. Negroes are generally 
supposed in America to be much less afflicted with cancer than the 
white race. In England statistics show that there are about 30,000 
patients suffering at all times from cancer. 

In the Tenth Census of the United States (1880) Billings states that the 
number of deaths during the census year was 13,068, of which 4875 were 
males and 8193 were females. He found also that cancer is most frequent 
among farmers, hotel- and restaurant-keepers, carpenters and joiners, physi- 
cians, clergymen, and sailors, while it is comparatively rare among printers, 
railroad officials, clerks, government officials, factory operatives, miners and 
iron- and steel-workers. An interesting map prepared by Billings shows 
that cancer is especially prevalent in the New England States and on the 
Southern Pacific coast ; that it is prevalent in New York, Pennsylvania, 



644 SURGICAL PATHOLOGY AND THERAPEUTICS. 

and Ohio, in the interior of Michigan, and in the southern part of Wis- 
consin. It is least prevalent in the Mississippi Valley and in the South, 
and the proportions are generally lower in the coast regions than in the 
interior. 

According to Park, the mortality from cancer is larger in and 
about Western New York and the adjoining region than in any 
part of the country save a limited area in California. Shattock 
has recently called attention to the fact that cancer, like tubercle, 
may repeatedly show itself in certain houses. This author reported 
a series of four cases of cancer occurring within fourteen years in 
persons unrelated by blood who were living in a single house. 
Power reports the history of three housekeepers who slept in suc- 
cession for several years in the same bed-room. The first lived in 
the room for thirteen years and died of cancer of the stomach; the 
second after a residence of twenty years died of cancer of the liver; 
the third died at the end of eight years of cancer of the breast and 
uterus. They were all in good health at the time of their instal- 
ment in the position. Chapman reports a series of three successive 
unrelated occupants of a house who became affected with cancer of 
the rectum. 

The cancer-cells, by their peculiar form, indicate their origin 
from epithelium. They are large cells of varying sizes and shapes, 
containing one or more round or oval nuclei with large, glistening 
nucleoli. They retain more or less the appearance and arrange- 
ment of the parent cells, so that the descendants of epidermic cells 
have the rough edges and a tendency to the horny change, and 
those which grow from cylinder epithelium have a tendency to re- 
main cylindrical ; but this is not always so, and in consequence of 
the rapid growth the cells are crowded into various shapes and they 
assume a polymorphous type. The departure from the anatomical 
type is so great at times that the new growth, although still epi- 
thelial, might with justice be regarded as a caricature of the nor- 
mal cells. 

The stroma, which is composed of fibrous tissue, is usually more 
or less infiltrated with small round cells. It may be abundant or 
scanty. When there are few epithelial cells the stroma makes up 
the greater part of the tumor, and there is a dense, hard growth, 
but when the epithelium appears to predominate the trabecular, 
which separate them into different clusters, are thin and the growth 
is soft. If the cut surface of a soft cancer be scraped with the 
sharp edge of a knife, there is obtained a milky fluid, the so-called 
sue canckreuse, which was supposed to be a diagnostic sign of can- 



CARCINOM. I. 645 

cer, but which is merely the fluid and the pulpy tissues that contain 
the cells. There is nothing specific in the appearance of these 
cells. Usually there are several clusters of cells adherent to one 
another, which are suggestive of cancer, but a positive diagnosis 
can be made only with the microscope, when the epithelial cells 
are seen lying in their alveoli. 

Cancer begins to grow by multiplication of the epithelial cells 
of the part. If the very first change seen in a cancer of the breast 
be studied, a proliferation of the epithelium of an acinus will be 
found, so that it becomes distended with the growth. The hyaline 
membrane of the tunica propria presently disappears, and later the 
outer layer. The epithelial growth now breaks through into the 
surrounding connective tissue and makes its way along the route 
of the lymphatics. The rapidity with which such a growth may 
take place depends largely upon the power of resistance of the sur- 
rounding tissues. The thin walls of a gland or a duct may yield 
readily, but the thick layer of the corium is much more resistant, 
and carcinoma in this region pursues, therefore, a much more 
chronic course. 

The route through which cancer spreads to distant parts is 
through the lymphatic system. In this respect it differs from 
sarcoma, which spreads much more frequently through the blood- 
vessels. The cells are pushed forward chiefly by the pressure 
caused by their growth. It is possible that they may progress 
also in virtue of active movements that have been observed in 
them (Carmalt). The lymphatic glands are affected early in the 
disease. 

In a case of cancer of the breast which the writer removed recently the 
patient was able to state the exact date of its origin, the place where the 
growth was formed having been examined a day or two before. The opera- 
tion was performed when the growth was three weeks' old, and already a 
nodule the size of a small pea was found in a lymphatic gland of the 
axilla. 

If such a gland be examined, at first the lymph-spaces will be 
found crowded with cancer-cells. The tissue of the gland is soon 
invaded, however, and it becomes plugged by the new growth, so 
that the disease is arrested for the moment at this particular point. 
Later the cells grow into the neighboring tissue and the process of 
infection continues. As the cancer spreads it becomes more vigor- 
ous in its growth, and during the later stages of the disease it destroys 
dense fascia and even bone. It progresses here by substituting its 
tissue for that of the organ which it invades. Occasionally it may 



646 SURGICAL PATHOLOGY AND THERAPEUTICS. 

be carried through the blood-vessels in an embolus to a distant 
organ. The internal organs that are most frequently the seat of 
metastatic deposits are the lungs and the liver. The secondary 
deposits are usually nodular in character, but occasionally there 
may be diffuse infiltration of an organ, as if the capillary vessels 
had been filled with an infective mass of cancer. 

The secondary nodules, as a rule, show a strong resemblance in 
their structure to that of the original growth; even some of the 
degenerative changes seen in the primary growth may be repeated. 
Occasionally in rapidly-growing cancers the metastatic growths 
may depart from the original type, and in some cases the cell- 
growth is so active that the alveolar arrangement seems to be lost, 
and it is only by careful study that carcinomatous structure can be 
demonstrated. In such rapid forms of growth a general metasta- 
sis may take place, to all parts of the system probably, by multi- 
ple minute emboli. Such a condition is termed an acute miliary 
carcinosis. 

The constitutional disturbance caused by the disease is known as 
the cancerous cachexia, and it consists in rapid emaciation, anaemia, 
and loss of strength. The growth of cancer is supposed to produce 
this condition in virtue of the injurious influence which it exerts 
upon the organs. It also abstracts material from the system for 
the nutrition of the growth. Rindfleisch assumes that the normal 
epithelial cells aid in the elimination of certain chemical substances 
from the system. When, however, these cells are enclosed in spaces 
in the interior of the tissues, as in cancer, the substances cannot be 
thrown off, and at the same time the products of the degenerative 
processes that are going on in the growth are carried into the cir- 
culation, and they exert a poisonous influence upon the blood. 

The retrograde changes seen in cancerous growths show them- 
selves often quite early. Cancer-cells are prone to undergo fatty 
degeneration, particularly those remote from the supply of nutri- 
ment. In this way the central portions of a nodule break down 
and a central depression is seen. In cancer of the skin ulceration 
takes place in virtue of these changes. Many forms of cancer 
undergo colloid degeneration, which involves frequently not only 
the cells, but also the stroma. As this change frequently occurs 
in the beginning of the disease, it gives a character to the growth 
that places it among the special forms of cancer to be noticed pres- 
ently. Calcification is occasionally seen in cancers whose growth 
is feeble. As the carcinomatous tissue is an imperfectly organized 
one, and as the walls of the blood-vessels are softened by cell- 



CARCINOMA. 647 

growths, frequent hemorrhages and necroses occur, and consid- 
erable portions of the diseased mass break down and are absorbed. 

The carcinomata are divided into certain groups according to 
differences which exist in the nature of the cells. Those cancers 
consisting of pavement epithelium constitute the variety to which 
the name epithelioma was given. This term, which was used 
before it was recognized that all cancers were epitheliomatous, 
was intended to represent a class of cancers that were less malig- 
nant in their type. The name is still retained, principally for this 
reason. " Epitheliomata " are situated upon the skin, but they may 
likewise be found upon the vagina and the cervix uteri and in the 
mouth and the oesophagus. Cylinder-cell carcinoma is composed 
of cells such as are found on intestinal mucous membranes. This 
form of cancer, which has a strong resemblance to glandular tissue, 
is therefore frequently called " adeno-carcinoma " or malignant 
adenoma. Carcinoma of the breast is characterized by the pres- 
ence of a more globular type of epithelium. It is, however, 
chiefly in those cancers where the type of epithelium is very 
striking in its appearance that the cell-names are given, such as 
pavement- and cylinder-epithelial-cell carcinomas. 

Cancers may be divided into several groups, according to their 
coarse appearances, which are due principally to the relative amount 
of cells and stroma of which they are composed. Thus, cancers of 
the breast, where they contain a large amount of epithelial cells ar- 
ranged in a delicate alveolar stroma, are necessarily soft and juicy; 
consequently, they are known as medullary cancers. Those cancers 
containing an abundant dense stroma, in which a few small alveoli 
are found, have but few cells, and they are known as scirrhous or 
hard cancers. Carcinoma simplex is a name given to denote an 
intermediate stage of density, but this term is rarely used. The 
medullary forms are, as may be supposed, much more malignant 
than the scirrhous. 

Colloid is a name given to those forms of cancer in which the 
cells have undergone colloid degeneration. This variety is found 
in various regions of the body, and the same type of cell does not 
always prevail. 

The colloid cancer should not be considered as a special 
variety, but rather as a form of degeneration. The colloid 
material is deposited in the cells at first in small drops which run 
together, and eventually the whole cell is altered. The cells 
break down and many of them disappear, and the alveolus 
becomes distended. The tissue is very transparent, and, as little 



648 SURGICAL PATHOLOGY AND THERAPEUTICS. 

is seen but large alveoli formed by the absorption of many of the 
trabecular, this variety is sometimes called "alveolar cancer." 
There is some difference of opinion as to the origin of the colloid 
matter. Some think it is elaborated by the cell; others assume 
that it is exuded by the vessels; Miiller suggests that it is 
developed first in the stroma. These cancers are seen principally 
in the stomach, the intestine, and the peritoneum; they are found, 
though rarely, also in the breast. The writer has seen a typical 
colloid-cylinder-cell cancer growing from the nasal mucous mem- 
brane. The development of colloid cancer is unusually slow. 
This peculiarity is attributed to the change in the cells, which 
interferes with the rapidity of its growth. 

When the cells of a cancer are filled with granules of pigment 
there is presented a variety known as melanotic carcinoma, but 
this form is exceedingly rare. 

"Endothelioma" is a name given to certain varieties of car- 
cinoma by pathologists who wish to distinguish those forms 
that originate from endothelium from those forms which develop 
from epithelium. The cells of these tumors closely resemble 
those of epithelial cancers, and it is quite difficult to distinguish 
between them. They may often appear as pavement-cells or as 
cylinder-cells. A differential diagnosis can only be made in such 
cases when it is possible to determine the exact point of origin of 
the tumor. They are found in the skin, in the meninges, and in 
the serous cavities, where they are often seen as disseminated 
miliary nodules. This distinction is one rather of scientific than 
of practical interest. 

A practical method of division of cancers is one based upon the 
localities in which they grow; therefore there will be described 
separately cancers of the skin, of the breast, of the uterus, of the 
mucous membranes, etc. These groups correspond pretty ac- 
curately to the different types of cancer-cells which have already 
been described, for the cells of a cancer resemble always the 
epithelial cells of the region in which they first appear. 

1. Carcinoma of the Skin. 

Cancers of the skin belong to that variety known as epithelioma 
or pavement-cell epithelioma. There are, however, two varieties 
of the disease, which may be distinguished not only by their 
histological, but also by their clinical, peculiarities. These 
varieties are, first, the superficial form, which is composed largely 
of a single type of small epithelial cell; and the deep-seated or 



CARCINOMA. 



649 



polymorphous type, which is composed of large pavement-cells 
and of small epithelial cells. The superficial form, which is a far 
less malignant type of cancer, is found on the face principally, 
and is often known as a rodent ulcer. The deep-seated form is 
found on the lip, the penis, the scrotum, and the back of the 
hand, and, although much less malignant than other forms of 
cancer, is more frequently followed by infection of the lymphatic 
glands than the superficial variety. 

The deep-seated form begins as a growth of cells from the epi- 
thelial layers of the skin, from the interpapillary space, and, ac- 
cording to some authorities, from the hair-follicles and the seba- 
ceous glands. The first change usually noticed is an enlargement 
of the interpapillary masses of epithelium, which masses become 
elongated and grow down into the connective-tissue spaces of the 
cutis. They branch here in various directions and become con- 
stricted and distorted, and finally they are found in the deeper tis- 
sues of the skin separated from the epithelial layers above. The 
connective tissues in which they are now imbedded form a vascular 
stroma rich in cells. The cells of these epithelial clusters have 
more or less the characteristic peculiarities of the epidermic cells. 
A careful study of their shape shows that the outer layer is com- 
posed of a more or less perfectly formed epithelium, resembling the 
layer of cells found in 
contact with the papillae 
of the skin. The cells 
nearer the centre are of 
the large pavement type, 
and in consequence of 
the rapid growth they 
are squeezed together 
and form concentric cir- 
cles of cells, which are 
flattened out and undergo 
horny degeneration. In 
this way are formed the 
"epithelial pearls" or 
"cell-nests," as they are 
called (Fig. go). If a fresh 
specimen of this form of 
cancer is cut open and 
the surface is slightly squeezed, there will be pressed out little comedo- 
like plugs which are composed of these epithelial nests. 






\m,% 




mm 




h 






»*« 






* 






ml 



3 



Fig. 90. — Cell-nests in Cancer of the Lip (oc. 3, obj. D.). 



650 SURGICAL PATHOLOGY AND THERAPEUTICS. 

In some of these epithelial pearls is occasionally found one 
of the so-called " psorosperm ' ' bodies, appearing as a mass of 
nucleated protoplasm which has shrunk away from the sur- 
rounding cells, leaving a space or vacuole. There is seen in 
this type of cancer, growing luxuriantly, all the cells found in 
the normal epithelial layers of the skin. There is not only the 
small-cell, which is found in the deeper layers of the rete mu- 
cosum, but also the large pavement-cells, and even the horny cells 
of the epidermis. We have, then, a polymorphous type of epithelial 
growth. It is not always easy to see the points from which spring 
these masses of cancer-cells. Usually they spring from the deep 
layers of the rete. Many of the sections made show clusters of 
cells which appear to be altered and degenerated sebaceous glands. 
The transition changes, however, are not easy to observe, and the 
writer has been unable to trace such growths from the sebaceous 
glands, although most authorities agree that these glands are often 
the starting-point of the disease. It is an interesting fact that 
clinically there is seen considerable disturbance of the sebaceous 
glands in many cases of carcinoma cutis. 

The superficial form of cancer of the skin is, as before noted, 
much less malignant, and there is found here a very different type 
of cell-growth. The cell-masses in most cases appear to grow 
down from the deep layers of the rete into the cutis vera in 
columnar masses which anastomose freely with one another. The 
epithelium is small and delicate, and it reminds one strongly of 
that seen in the rete mucosum near the borders of the papillae or in 
the sheath of the hair-follicle. These columns of cells occasion- 
ally swell into large and irregular shapes, and there is found at cer- 
tain points in such clusters a larger epithelium around which there 
is a concentric arrangement of cells; but these epidermic balls are 
extremely rare. In many cases the amount of epithelium is very 
small for cancer, and the stroma, which is composed of dense 
fibrous tissue, seems to make up the greater part of the growth. 
In such cases there is presented a delicate anastomosing network of 
columnar masses of cells, such as is described by the French writers 
as epitheliome tubule (Fig. 91). It is claimed by Thiersch and 
others that this variety takes its origin from the sudoriparous 
glands, and by some writers it is known as adenoma of the sweat- 
glands. These cell-masses, whatever their shape or size, grow 
very slowly, and they remain for a long time confined to the upper 
layers of the skin. When the number of cells is very small and 
the stroma predominates, there is quite a dense, hard growth, and 



CARCINOMA. 651 

the name scirrhus cutis has sometimes been applied to this 
condition. 

From what has been written it is evident that the cancer-cells 
spring from pre-existing epithelium: this is a fact which long 





4 










<». 








# 






■•'■v 




**# 








1 








~<£ 










■y / 


% 




;*..- 






Fig. 91. — Tubular Epithelioma, from a case of Rodent Ulcer (oc. 6, obj. aa.). 

since has fully been settled. It is learned also that as cancer grows 
its epithelial cells appropriate everything that comes in their path, 
and that bone, muscle, and nerve all seem to melt away before the 
active cell-growth. In some of the writer's early investigations it 
seemed, when one studied carefully the outer edge of a cancerous 
growth, that the spaces first filled with cells did not always contain 
epithelial cells, and that the clusters of round cells as one approached 
nearer the centre of the disease gradually became epithelial. This 
suggested that the round cells in some way had to do with the 
development of the cancer-cells. French writers speak of the 
action of the epithelium on the round cells as an "action de pre- 
sence" the young cells becoming in this way impregnated and 
endowed with epithelial properties. However these appearances 
may be interpreted, the fact remains that in rapidly-growing carci- 
noma the round cell infiltration of the surrounding tissue is 



652 SURGICAL PATHOLOGY AND THERAPEUTICS. 

abundant and the cancer-cells present an appearance less typical of 
epithelium. This view is held also by Rindfleisch. Gussenbauer 
maintains that not only the endothelium of the capillaries, but also 
the muscular fibres from the media, form embryonic cells which 
develop into cancer-cells. Weil has also observed similar changes 
in striped muscular fibre (V. Ziemssen). 

Carcinoma of the skin occurs most frequently between the ages 
of fifty-five and sixty. In 948 cases collected by V. Ziemssen, 739 
were men and 209 were women. 

The superficial form of cancer is almost invariably found on the 
face, and it has frequently been called " rodent ulcer." This term 
was used before the pathology of the disease had been recognized, 
and it describes one of its most striking clinical peculiarities. 
Cancer of the face — and it might also be said cancer of the skin 
in general — is apt to be accompanied by a peculiar condition of 
the epidermal structures known as keratosis. 

This affection is characterized by the formation on the face and 
the back of the hands of scabs or crusts, which exist for a long 
time before any malignant disease manifests itself. At first they 
appear as scales, slightly elevated above the skin surface and of 
somewhat darker color than the surrounding skin. The surface of 
the spots is sometimes shining and smooth, and is sometimes dry 
and covered with minute lightly-adherent scales. The spots are 
without sensation and attract little attention at first. Gradually 
they become more noticeable by increase in elevation and in depth 
of color, but their development is very slow, and years may pass 
before they attain sufficient growth to become troublesome. 
Eventually they present elevations, one-eighth of an inch above 
the general surface, consisting of dry, horn-like scales, which 
vary in color from the faintest yellow to the deepest black, 
and which may be removed with little violence by the nail, 
leaving exposed a superficial excoriation, either smooth or exhib- 
iting minute conical elevations that are enlarged sebaceous glands 
(White). 

Microscopically, there is seen a great thickening of the upper 
horny layer of the skin, which thickening is continued downward 
into the ducts of the sebaceous glands, distending them and form- 
ing prominent protrusions. The sebaceous gland is not changed, 
but it is much distended by retained secretions which become 
mingled with the epidermic crusts. There is more or less cell- 
infiltration in the surrounding corium. The appearance of the 
complexion is often characteristic. There is a peculiar wax-like 



CARCINOMA. 653 

transparency of the temples and the upper part of the cheeks, and 
just beneath the surface of the skin can be seen the yellow sebace- 
ous glands. The true skin is thin and is in a state of senile 
atrophy. At some one spot a crust has gradually become more 
prominent than elsewhere: this may be upon the side of the nose 
or be over the malar bone or on the temple. On picking off this 
crust it is now seen that there is beneath it a papule with a moist 
and somewhat ulcerated surface. On excising this papule it will 
be found that a downward growth of epithelium has taken place 
and that the development of the cancer has already begun. 
Schuchardt interprets the series of changes just described as the 
symptoms of a chronic inflammatory process which is, he thinks, 
highly favorable to the development of cancer. He failed, how- 
ever, to find that the sebaceous glands were in any case the point 
of origin of the malignant growth. 

The superficial carcinoma begins usually after middle life, is 
extremely slow in its progress, and, inasmuch as it does not cause 
pain, and sometimes not even itching, it is neglected for many 
years, and it is therefore often not seen by the surgeon until it 
has assumed large dimensions. When observed in the early stage 
of development it is found that the new formation has broken down 
in the centre and an ulcer has formed. The ulceration is not deep, 
and the surface is quite flat and is surrounded by a pearl-colored 
rim. The shape often closely resembles that of a horn waistcoat- 
button. Around the edge of the ulcer the skin appears in a healthy 
condition. The absence of inflammation in the diseased, part is 
characteristic of cancer. There is no red and infiltrated skin, as 
is seen around tubercular or syphilitic ulcers. The pearl color of 
the rim is due to the presence of the epithelial cells, and it is 
characteristic of this form of cancer. When there is extensive 
breaking down of tissues and inflammatory complications the pres- 
ence here and there of fragments of this pearly rim, perhaps made 
visible by the use of a hand lens, will enable the surgeon to recog- 
nize the disease under its disguise. 

As the growth slowly advances its ulcerating character becomes 
more apparent: it may take years to double in size. Sometimes 
one portion of the rim will suddenly begin to grow out of all 
proportion to the other parts, and the ulcer is replaced or is 
masked, as it were, by a tumor. Usually, however, it continues 
to spread slowly, but is still as superficial as ever, and if the 
patient lives long enough it may cover large surfaces, involving the 
nose, the eyelids, the eye, and even the whole side of the face. To 



654 



SURGICAL PATHOLOGY AND THERAPEUTICS. 




Fig. 92. — Noli-Me-Tangere. 



this formidable condition the term noli-me-tangere has appropriately 
been applied (Fig. 92). In the case of the patient whose portrait is 

here given (Fig. 92) there 
was no enlargement of the 
lymphatic glands. The 
same absence of glandular 
involvement was observed 
recently in another indi- 
vidual, in whom there was 
extensive ulceration. The 
disease had in this case 
originated in the scar of 
a gunshot wound received 
during the Civil War, and 
had destroyed the side of 
the nose, the eye, the ear, 
and the cheek, including 
the corresponding half of 
the upper and lower lips. 
The slight malignity 
of these 

of cancer has been 
plained by the feeble reproductive power of the small epithe- 
lial cells, but it is more probable that there are other factors 
to be considered, such as the anatomical seat of the disease and, 
possibly, the nature of the parasite — if there be one — which 
caused it. 

Carcinoma of the face does not always ulcerate. Occasionally, 
and not infrequently, the growth of epidermal cells is abundant, 
and there is also an active development of the stroma, so that 
there arises a nodular or papillary form of growth. These tumors 
may sometimes attain considerable size, reaching the dimensions 
of an English walnut. Such growths, which have been described 
by Hutchinson as a fungating form of rodent cancer, are found on 
the temple or near one of the lids. When such exuberant growths 
break down prematurely, there is formed a deep ulcer with raised 
edges, and this appearance Hutchinson named " crateriform " 
ulcer. Such growths, though formidable in appearance, are not 
liable to recurrence if they are so situated that they can radically 
be excised. One of the most important strategic points of cancer 
of the face is the region over the nasal process of the superior 
maxilla. A carcinoma originating here or gradually working its 



ulcerating forms 



ex- 



CARCINOMA. 655 

way toward the inner margin of the orbit may suddenly involve 
the lymphatic vessels leading to the base of the skull. When 
once the margin of the orbit has been passed the disease may be 
regarded as incurable. 

There is a period in the life-history of this disease when the 
benign type may suddenly be changed to a malignant type, and a 
superficial cancer will then be transformed into the deep-seated 
variety. Irritating modes of treatment often rouse a sleeping can- 
cer to frightful activity. 

The deep-seated or polymorphous-cell cancer has its type in 
cancer of the lip. Here also the disease has been ascribed to 
chronic irritation, in this case the irritant being the constant use 
of tobacco. 

Mason Warren reports 77 cases of cancer of the lower lip. It 
w r as ascertained that all but 7 w T ere in the habit of smoking. In 
many cases the fact of a habit of smoking could not be ascer- 
tained, but the interesting feature of this series w T as the fact that 
4 were women, 3 of whom were in the habit of using a pipe. The 
writer remembers having seen but one case of cancer of the lip 
in a woman, and she was in the habit of smoking. In this case 
the cancer was in the upper lip. So many smoke, however, who 
do not have cancer that it must remain doubtful whether such 
a cause predisposes to cancer. 

According to Mason Warren, the disease is seen oftener on the 
left side of the lip than on the right ; it may occur on the median 
line. Like other forms of carcinoma of the skin, it appears after 
middle life, and is commoner between the ages of sixty and seventy 
than at any other period ; occasionally it is seen between the ages 
of thirty and forty, and in the latter case the disease is much 
more active. The point at which the disease begins is the junc- 
tion of the mucous membrane with the skin, and it appears either 
as a small papule or as a flat crust which falls off only to re-form. 
It soon assumes the appearance of a superficial infiltration of the 
vermilion border of the lip, and it has a well-marked, though 
shallow, circular outline. When examined under the microscope 
at this period the disease is found to consist in a thickening of the 
epidermal border of the lip. The outer papillae are thickened 
and elongated, and as the centre of the disease is approached the 
downward growth of the epithelial cells is w r ell marked. The 
disease, however, is still very superficial. The large epithelial 
cells are seen here, and the number of epithelial pearls is very 
great. When allowed to pursue its course the disease may involve 



656 SURGICAL PATHOLOGY AXD THERAPEUTICS. 

a greater portion of the lip, and even attack the bone. The cen- 
tral portion is then ulcerated, and the ulcer is surrounded by thick 
and overhanging edges. The next point of attack is the sub- 
maxillary gland of the side on which the disease lies. This point 
can be felt readily by standing behind the sitting patient and 
pressing the tips of the fingers against the inner margin of the 
jaw-bone. A small bullet-like nodule rolls between the bone and 
the finger. In the later stages of the disease the glands of the 
neck become enormously enlarged, and the patient dies slowly with 
symptoms of marked cachexia. Metastatic nodules may be found 
in the internal organs, but they are not common. 

The prognosis of the disease is favorable if an operation is per- 
formed while the growth is superficial ; this is not always the case. 
The writer remembers a physician who applied for operation about 
three months after the first appearance of the disease. There was 
no return in the lip, but a gland under the jaw began to enlarge 
six months later, and the patient succumbed eighteen months 
after the first appearance of the disease. 

The question of operation upon infected submaxillar}' glands 
is one about which there is much difference of opinion. When 
small and movable the glands should undoubtedly be extirpated 
bv a verv free and extensive dissection of the region in which thev 
lie. Under these circumstances the prospect of a final cure may 
be looked forward to with some hope of success : it is, however, 
a grave complication of the disease. After operation patients 
frequently return in a few months very much alarmed about an 
induration of the cicatrix. Such cicatrices are not infrequently 
excised, and it is then found that there is nothing but cicatricial 
tissue. If let alone the induration will eventually disappear. 

Cancer on the back of the hand is of the same type as cancer of 
the lip. It is associated usually with marked keratosis senilis. 
Although polymorphous, the cancer grows slowly at first, and a 
papule covered by a crust may exist for years before the patient 
seeks relief. Such growths are not infrequently multiple. The 
danger is that the glands at the elbow may suddenly become 
involved. In one patient who suffered from this affection the 
writer removed four or five such growths, not only from the hands, 
but also from the face. Axillary involvement eventually took 
place, and after seven or eight years' duration the disease finally 
terminated life by metastatic deposits in the liver. The writer has 
also seen cancer originate upon the palmar surface of the hand In 



CARCINOMA. 657 

a case of palmar psoriasis. This case likewise terminated fatally, 
notwithstanding amputation at the wrist. 

Cancer of the penis occurs in about 1 per cent, of all cases of 
cancer. It is seen most frequently between the ages of forty and 
seventy years. It may occur on the preputial fold, but it is oftener 
seen on the glans. It can be distinguished without difficulty 
from chancre or a syphilitic condyloma by the history of the case, 
as the growth is very slow. It is said to appear at first as a small 
vesicle or a wart on the frenum, which vesicle increases in size and 
develops into a papillary growth. As it enlarges the centre breaks 
down and leaves an ulcerated surface. It may remain localized for 
a long time, the tunica albuginea appearing to offer considerable 
resistance to the growth, but eventually it attacks the body of the 
organ and infiltrates the lymphatic vessels and the glands in the 
groin. The glandular infection is said by Kaufmann to be more 
frequent than is generally supposed. In 48 cases, 40 were found to 
have this complication. The glands in the groin are the first 
involved, and usually those near the point of junction of the 
saphenous and femoral veins. Occasionally the glands in both 
groins are affected. Phimosis, accompanied with more or less 
balanitis, is seen frequently in this disease. Demarquay found in 
59 cases, 42 in which there was phimosis. The writer remembers 
two such cases which were cured by operation. Metastases are 
occasionally found in the internal organs. The disease runs its 
course if untreated in from one to two years. Kaufmann found the 
average duration of life in 38 cases to be twenty-two months. If 
the disease comes into the surgeon's hands early, the prognosis is 
favorable for minor operations. 

Carcinoma of the labia is of the same type as that of the 
penis. It appears usually on the inner surface of the labia majora, 
and it is first seen as a circular ulcer. It might be mistaken for a 
syphilitic lesion, were it not that there is an absence of inflamma- 
tory change and a history of slow growth. If allowed to follow its 
course, it may extend around the ostium vaginae and destroy the 
clitoris. The mons veneris may be undermined by an extensive 
infiltration, and the vulva is then converted into one large foul, 
ulcerating surface. The glandular involvement comes late. The 
disease is more malignant than cancer of the lip. It generally runs 
its course, if untreated, in about two years. Butlin, in an analysis 
of 31 cases operated upon, places the percentage of cures — that is, 
of those who have passed the three-year limit — at 16. If the dis- 
ease is operated upon before glandular enlargement occurs, the 

42 



658 SURGICAL PATHOLOGY AND THERAPEUTICS. 

chance of a radical cure is good. Owing to delay while trying 
specific or local treatment this golden moment is often lost. 

Cancer of the scrotum is also of the large- or polymorphous-cell 
type. It appears to be a disease almost exclusively confined to 
English chimney-sweeps; hence it has been called "chimney- 
sweep's cancer." It was supposed to have disappeared since the 
law has been enforced forbidding sweeps to ascend flues; Butlin's 
investigations, however, show that this is not the case. In the St. 
Bartholomew Hospital in the course of twenty years 39 patients 
were treated for cancer of the scrotum. In the Middlesex Hospital 
from 1867 to 1882 there were 20 cases of cancer of the scrotum 
under treatment. At the St. George Hospital 9 cases were treated 
from 1869 to 1878. The statistics of the Registrar General show 
that during a period of three years there w r ere 23 deaths from can- 
cer of the scrotum, penis, testis, or groin. 

A careful investigation by Butlin of the various hospitals of 
Europe shows that the chimney-sweeps in Continental Europe do 
not suffer from this form of cancer: this immunity he attributes to 
the protective costume worn by them and to their personal cleanli- 
ness. In England, although chimney-climbing has been aban- 
doned, no efforts were made to protect the body from the soot 
which falls in greater or lesser quantity upon the sweep. In the 
United States the disease is extremely rare. At the Boston City 
Hospital from 1881 to 1889 there occurred but 1 case of cancer of 
the scrotum. The writer remembers having seen but 1 case at the 
Massachusetts General Hospital, and that was thirty years ago. 

The disease begins as a wart. Many such warts form on the 
scrotum and are known as ' ' soot-warts. ' ' They may exist for 
years, and some sweeps are covered with such warts upon the scro- 
tum without suffering from cancer. In the course of time, owing 
probably to some special irritation, one of the warts slowly grows 
larger, becomes more prominent, and at the same time becomes 
deeply fixed, and its centre ulcerates. The cancer spreads slowly 
along the scrotum, being confined to the skin. Occasionally it 
penetrates more deeply until it reaches the tunica vaginalis, and 
even the testicle, which may be laid bare and in time be destroyed. 
Before the days of anaesthesia the disease was said often to destroy 
everything from the anus to the pubes, leaving a foul sore against 
which no treatment availed. 

Secondary infection of the glands of the groin may occur late in 
the disease. Metastatic deposits in the internal organs are not 
reported, probably because autopsies are rare (Butlin). 



CARCINOMA. 659 

Tar and Paraffin Cancer of the Scrotum. — This disease was 
described almost simultaneously by Volkmann in Halle and Bell 
in Edinburgh. Ogston in 1871 had written on the local effects of 
crude paraffin. This disease occurs among the operatives in coal- 
tar and paraffin factories, who are obliged to be in contact with the 
products of the manufacture in a more or less liquid state. These 
products induce great irritation of the surfaces exposed, such as 
the skin of the forearms. The skin of the body is described as 
dry and parchment-like, somewhat resembling the irritation pro- 
duced by carbolic acid. The ducts of the sebaceous glands are 
dilated, and in the ducts are seen dark, comedo-like plugs, and 
acne-pustules abound. There is considerable thickening of the 
epidermic layer, which is raised into little prominences on the 
extremities as well as on the scrotum. Sometimes there is a 
more distinctly scaly condition. In new operatives there is con- 
siderable infiltration of the skin at some points, and the part is 
red and shining and is tender to pressure. In old cases, after the 
first acute irritation subsides, the epidermic thickening increases 
gradually. Warty growths appear, and finally at one spot car- 
cinoma develops. The series of changes is not unlike that seen 
in cancer of the lip. 

A histological study of the irritated skin shows a growth of the 
lower layers of the epidermis and of the rete mucosum. The 
hair-follicles are frequently distended with masses of epidermic 
cells, and in the deep layers of the rete are found spots of brown 
pigment. Near the carcinomatous nodules the dividing-line be- 
tween epidermis and the cutis becomes very irregular, and the 
interpapillary masses of cells are enlarged and irregular in shape. 
The skin shows also a small cell-infiltration. When the zone of 
the cancer is reached there are found enormous numbers of epider- 
mic balls and a polymorphous-cell growth into the deep layers of 
the cutis. It is evident that we have to do here with a chronic 
irritation of the skin affecting its epithelial structures for a long 
time, producing at first hypertrophy of some of these structures, 
and finally a tendency to indefinite growth, as in cancer. 

In the deep rugae of the scrotum the soot- or tar-products 
remain untouched for long periods of time, and it is here that 
the disease most frequently shows itself. It is possible, as Butlin 
suggests, that certain areas possess physiological and chemical 
properties, which differ from those of other areas of the integu- 
ment as decidedly as they do in their coarse appearance. It 
has been suggested by Butlin that the crude paraffin, the brown 



660 SURGICAL PATHOLOGY AND THERAPEUTICS. 

coal-tar, and the stone-coal soot have' specifically irritating qualities 
which favor the development of cancer. It has also been suggested 
that tobacco-smoke and tobacco-juice bear the same relation to 
cancer of the lip that these substances do to cancer of the scrotum. 

Xeroderma pigmentosum is a skin disease in which cancer is 
a frequent complication which appears in early life. 

Cancer in Cicatrices. — Cancer has been associated with scars 
by writers ever since Alibert described keloid, which he confounded 
with cancer. Cancer appears long after the scar is originally ac- 
quired, and it is seen most frequently in individuals from forty-five 
to fifty years of age. Males are said to be more frequently afflicted 
than females. Cancer seems to develop preferably in those scars 
which have been subjected to long periods of irritation. Cancers are 
found, therefore, in cicatrices of the limbs that hamper movement; 
consequently they are subjected to undue tension, or they are found 
in the scars of ulcers or of old wounds or of fistulae. Ulcers form 
and heal in the cicatrices many times before cancer develops. The 
greater part of a lifetime may pass in this condition, and finally 
the disease breaks out. Reid reports a case in which the disease 
appeared sixty-one years after the original injury. 

The scars of ulcers on the lower extremity often exhibit this 
peculiarity. The disease in these cases is usually of a mild type. 
There may be present the polymorphous- as well as the small-cell 
type of cancer, but the growth of the cancer is almost always 
exceedingly slow, and there is a history not unlike that of rodent 
ulcer. These cases may, however, take on a more malignant 
action at any time. In such cases there is likely to be found 
involvement of the inguinal glands. In 128 cases reported by 
Rudolf Volkmann of cancer developing in scars of the extrem- 
ities only 12 cases were known to have died of cancer. 

In a case recently operated upon the writer found a large ulcer, 
with a peculiar fur-like surface, that had evidently developed from 
the scar of an old varicose ulcer. It had already involved the 
shaft of the tibia, but, as it had existed for many years and had 
caused no pain, it was only with the greatest difficulty that the 
patient was persuaded to allow amputation of the limb. It proved 
to be a large-cell epithelial growth. The writer has already re- 
ferred to a most formidable case of rodent ulcer of the face that 
developed from a scar. 

The treatment of cancer of the skin, as indeed of cancer in gen- 
eral, may be stated to consist in the removal not only of all appa- 
rent disease, but also in the excision of as broad a margin as pos- 



CARCINOMA. 66 1 

sible of healthy tissue. In the case of cancer of the skin this 
treatment can be carried out more effectually than in any other 
portion of the body, and, inasmuch as glandular infection conies 
late in the disease, operation is more frequently followed by cure 
in this than in any other region. 

Rodent ulcer is perhaps the mildest type of cancer known, and 
in its earliest stages it can be scraped away, the base of the wound 
being bored with a caustic or touched lightly with the fine point 
of a Paquelin cautery. If the papule or ulcer is situated where 
it can be excised, this operation should be performed, as the wound 
heals speedily and leaves an almost imperceptible scar; and one 
should train one's self to take as much tissue as possible in order 
that the cure may be permanent. This is one of the hardest 
habits for the surgeon to acquire, as economy of tissue appears 
to be urgent upon exposed places. Occasionally a small nodule 
situated upon the side of the nose, if not radically removed, will 
begin to grow with frightful rapidity. Cancer of the face can per- 
manently be cured, even though it has returned several times after 
operation and has involved cartilage and bone. The writer recalls 
the case of a gentleman who allowed a cancer to grow on the left 
side of the nose until it involved the skin of that side and a portion 
of the skin of the right side. The disease returned three times after 
thorough scraping and burning with the actual cautery. Finally, 
the left half of the nose and the ascending process of the superior 
maxilla were excised, and the cavity thus left was covered by a 
flap taken from the forehead. The disease never returned after this 
operation. Beyond the use of the Paquelin cautery for exceed- 
ingly small growths, the writer has abandoned the use of caustics 
in the treatment of this affection, as the results of incomplete re- 
moval are occasionally most serious. 

Cancer of the lip should be excised by a V-shaped incision, 
including at least one-quarter of an inch of healthy tissue on each 
side. There is no danger of taking away too much, as the lip is 
elastic and its suppleness is entirely restored even when very large 
portions have been removed. Careful examination should always 
be made to detect infected glands, and the patient should be warned 
to search for the appearance of any lump under the jaw. A very 
free dissection of the upper cervical triangle may even then give 
the patient a chance for his life. 

Cancer of the penis, when operated upon early, is curable. The 
disease should be scraped away, and the base of the growth should 
be sliced off as one would pare a corn until healthy cavernous tis- 



662 SURGICAL PATHOLOGY AND THERAPEUTICS. 

sue is seen. In more advanced stages amputation should be per- 
formed, and the groin should carefully be searched for enlarged 
glands. Winiwarter reports 12 amputations, of which 5 remained 
permanently well ; 1 died of the operation ; 6 had recurrences, 3 of 
which were in the stump and 3 in the glands. If the glands are 
removed early, there is still hope of cure, as the progress of the 
disease is slow. The bad reputation of this form of cancer is un- 
doubtedly due to many incomplete operations; the same may be 
said of cancer of the vulva. Time is frequently lost in determin- 
ing the diagnosis and in using specific remedies. 

The writer succeeded in prolonging life for several years by 
yearly operations on a case of advanced cancer of the vulva, so 
that at the present time there is no vulva. The meatus and 
ostium vaginae, much narrowed, now open in the centre of a cica- 
trix. A few months ago the patient was seen in good condition. 

The treatment of cancer of the scrotum is attended with good 
results if taken in the early stages. The rule of free excision 
holds good here. 

In cancer of cicatrices the disease is generally found in the 
centre of a large scar. If this scar is situated on an extremity, 
there is an excellent chance of saving the patient by an amputa- 
tion, as the glands in the groin are usually not infected, although 
they may be enlarged by inflammatory infiltration. If the scar is 
situated on the face or the trunk, the best that can be done is 
probably a thorough curetting followed by the actual cautery. 
In some cases it would be possible to excise the ulcer, the wound 
thus made being covered by Thiersch grafts. 

The tendency at the present time of following up the operative 
treatment of cancer by a subsequent course of internal medication 
should be encouraged. In the case of cancer of the skin the bro- 
mide of arsenic or Fowler's solution may be tried in doses of 2 or 
3 drops three times a day for months after the operation. Patients 
should be asked to report every three months during the following 
year for inspection. 

2. Carcinoma of the Breast. 
The breast is one of the most frequent seats of cancer. In a 
series of 7881 cases of cancer collected by Andrews the disease 
appeared in the breast 1232 times. This region comes third upon 
the list, following that of the uterus and the stomach. In the 
great majority of cases it occurs in the female breast, and in the 
male breast the disease is extremely rare, being seen in about 1 per 



CARCINOMA. 663 

cent, of the cases. In a collection of 1 10 cases of cancer of the breast 
made by Dietrich 3 occurred in males. The number of deaths from 
cancer of the breast reported in the United States in 1880 was 1387. 

The period of life in which the disease is oftenest found is that 
immediately preceding the menopause. In an analysis of 1622 
cases Gross found that the average age was 48.66 years. It may 
be said that from forty to fifty is the commonest decade in which 
the disease is likely to occur; it is next most frequently found in 
women between fifty and sixty years of age; the period from thirty 
to forty years comes next, and that ranging from sixty to seventy 
follows. There is but one case reported at the age of twenty-one, 
but Bryant states that he has seen cancer of the breast at an earlier 
age. The writer had one patient in whom the disease was first 
noticed when she was twenty-two years and three months old. It 
was a well-marked case of cancer, as shown by microscopic ex- 
amination, and it recurred, after operation, the following year. 
Although the disease appears during the period of the functional 
decline of the organ, it is said that 80 per cent, of the cases are 
found among married women, and according to Bryant it appears 
to occur among women who are prolific to an extreme degree. 

The question of heredity having already been discussed, it 
remains merely to add here that of 1164 cases analyzed by Gross, 
in only 55, or 4.72 per cent, of the cases could the disease be said 
to have been transmitted. Traumatism, according to some writers, 
has a direct influence on the development of carcinoma of the breast 
in about 13 per cent, of the cases. Cancer of the breast in the negro 
is extremely rare. The writer does not remember having seen a case. 

As to the locality of the disease, it may be said that it occurs 
about as frequently in one breast as in the other. If a line be 
drawn vertically and one horizontally through the nipple, the 
breast will be divided into quadrants. If now a circle be drawn 
around the areola, the breast will be divided into five anatomical 
areas in which cancer may be found. The disease was found by 
Gross to be seated more frequently in the upper than in the lower 
hemisphere, and more frequently in the outer than the inner hem- 
isphere. The most frequent locality was found to be the upper and 
outer quadrant, that nearest the axilla, while the region of the areola 
came next in order. In exceptional cases it develops in an accessory 
gland or lobule below the clavicle, near the sternum, or in the axilla, 
where it may be mistaken for disease originating in a lymphatic gland. 
Cancer constitutes about 80 per cent, of all tumors of the breast. 

The classification of cancer of the breast varies considerably in 



664 



SURGICAL PATHOLOGY AND THERAPEUTICS. 



different works. The simplest and most practical arrangement is 
a division of the various forms into two classes — namely, medul- 
lary, or soft and rapidly-growing carcinoma; and scirrhous, or the 
hard or less malignant type. 

The cells of carcinoma of the breast are of a more or less 
globular type of epithelium. They are very irregular in shape 
and vary considerably in size. They are contained in alveoli, and 
are grouped together in no well-defined order, but fill the alveolus 
usually with a solid mass of cells which are directly in contact 
with one another. In the meditllary form the alveoli are either 
large or numerous, and they vary according to the shape of the 
plugs of cells that accumulate in the stroma. These plugs are 
sometimes round or oval in shape, and at other times are long and 
narrow, and cancers in which one or the other form prevails have 
been called by Billroth "acinous" or tubular. The stroma is 
composed of connective-tissue fibres in which there is more or less 
round-cell infiltration. It is sometimes exceedingly small in 
amount, only a few fibres forming the trabecular which separate 
the different alveoli, and in such cases the cell-masses or plugs 
are very numerous. The larger the number of cells the softer 
the tissue, and the term medullary is therefore a most appropriate 
one to describe such a condition (Fig. 93). In the periphery of 

the tumor the tissue which 
immediately surrounds the 
cancerous growth is usually 
infiltrated extensively with 
small round-cells. The stro- 
ma is not always the same 
in character throughout the 
growth, for at certain points 
it may be abundant, and may 
form broad fibrous bands 
which separate the soft cellu- 
lar portions from one another. 
This is the case in tumors of 
medium density, which are 
sometimes called "carcinoma 




Fig. 93.— Medullary Carcinoma of the Breast simplex "—a term frequently 
(oc. 3, obj. D.). used in books, but rarely 

employed by surgeons. 
In the scirrhous variety the stroma is a predominant feature of 
the new growth, and the cell-clusters are few in number and small 



rare instances found to undergo \ s* . , *$£i* 



broad semi-transparent bands ' c - ^i^^SpSS? 5* <: " 
of tissue, with a few pigment- 




ed RCINOMA. 665 

in size. The latter are found scattered at greater or lesser distances 
from one another, and are enclosed in elongated and spindle- 
shaped alveoli. They are in 

•or 

*o 

calcification. The fibrous stro- ?* ^ ' > " ,v \$?4 # , 

ma is very dense and scar-like 4 % &>r z ^*§ \ ^ ^ X 

at certain places, and the fibres '^jjfti^. "--a&^A^ 

often run together, forming ^ •« ''^jBJBfeAj*^ * " V ^V ^ 

granules scattered here and T&v*^ - f*^S^^ : 

there, but with very few cells 

(Fig. 94). In the extreme , -^ 2-3^ - -^* 

type of this form of cancer the ~~**<L,a «. 

cell-clusters are sometimes e -%tco 

quite difficult to find, and in n . ^^f-,%^ . ^ 

the early days of the micro- *z>[*j$?f' --V&V* 

SCOpe this form was called a Fig. 94.— Scirrhous Cancer of Breast (oc. 3. 

"connective-tissue cancer," as obj. D.). 

it was supposed that no epithe- 
lium existed in it. This type of scirrhus has been called 
"atrophying scirrhus;" the dense forms of cancer, being very 
slow in growth, are consequently much less malignant in cha- 
racter. 

The coarse appearances of these two forms of cancer also differ 
markedly from each other. The cut surface of a medullary cancer 
has a grayish-red color in which grayish striae are seen formed by 
the fibrous trabeculae which support the soft juicy masses of cells. 
There is no well-defined border, as the growth appears to infiltrate 
the surrounding tissues. By scraping lightly such a surface an 
abundant cancer-juice is obtained upon the blade of a knife, the 
juice showing under the microscope epithelial cells of most irreg- 
ular shapes, single or in clusters, and floating in a turbid serum. 
The scirrhous cancer when cut open shows a mass of scar-like tis- 
sue which has caught in its projecting bands of fibres portions of 
the lacteal ducts and of other structures pertaining to the breast, 
that are in a more or less advanced stage of atrophy. 

An unusual form of cancer of the breast is colloid cancer. It 
is so rare that the writer remembers having seen but two speci- 
mens. The appearance of a microscopical section is very striking. 
The alveoli are large and the stroma is thin and transparent. The 
alveoli appear to be distended with a transparent gelatinous mate- 



666 SURGICAL PATHOLOGY AND THERAPEUTICS. 

rial having circular streaks in it, as if it recently had been stirred 
with a glass rod. There are very few cells; sometimes one or two 
remain adherent to the wall of the alveolus, but more frequently a 
cluster of cells are found near the centre undergoing degeneration. 

An example of the earliest change found in the epithelial struc- 
ture of the breast in the development of cancer is seen near the 
periphery of a growing carcinoma. Here is found a growth of 
the epithelium filling up and distending a gland acinus. The 
hyaline membrane of the tunica propria of the acinus presently 
disappears, and the cells break through the deeper layers of the 
tunic into the surrounding tissue, and they begin to grow in dif- 
ferent directions in the lymph-spaces. 

Let attention now be turned to the clinical history of cancer of 
the breast. The first symptom noticed by the patient is a hard 
lump in the breast. It is only accidentally found, as there has been 
no previous pain and no symptoms of constitutional disturbance of 
any kind. When a healthy woman between forty and fifty years of 
age presents herself with such a lump, the chances are strongly in 
favor of its being a malignant growth. The nodule is usually seated 
in the upper and outer quadrant or beneath the nipple. To the 
touch the nodule appears to be firm and ill-defined as to its bor- 
ders. In some cases the nipple is retracted, and if the axilla be 
explored with the tips of the fingers, there will be found one or 
more glands firm and matted together that slip between the fingers 
and the ribs. Often there is no retraction of the nipple, but in 
many cases a careful inspection will show that the skin overlying 
the tissues is depressed slightly, forming a shallow dimple. This 
pitting of the skin and the retraction of the nipple are due to the 
shrinkage which has taken place in the breast-tissues in conse- 
quence of the destruction that has been brought about by the 
diseased growth. The lump in the breast slowly grows, and finally 
it becomes attached to the skin, which gradually becomes destroyed, 
so that there is found in the centre of a reddened and infiltrated 
lump an ulcer which gradually increases in size. In many cases 
the tumor forms without pain, but as the growth progresses there 
may be lancinating pains. Pain is not, however, an important 
symptom, as many women of middle age are apt to suffer from 
neuralgia of the breast, particularly at or near the menstrual 
period. In such cases the writer has noticed a slight fulness of the 
breast, and even an enlargement of the axillary glands. The con- 
dition is readily distinguished from cancer, however, as in such 
cases there is no tumor to be felt. The nodulated masses felt in 



CARCINOMA. 



667 



a mamillary gland should not be mistaken for a tumor, and the 
best way to determine definitely the presence of a new growth is 
to press the breast firmly against the thorax-wall with the palmar 
surface of three extended fingers. 

The tumor develops not only forward, but also backward into 
the pectoral muscle and the retromammary connective tissue. 
Even though the muscle appears to be free, the delicate fascia is 
often affected. The muscle may eventually become adherent to 
the growth, and later it may be perforated, and the tumor then 
becomes fastened to the ribs. This condition is recognized by the 
immobility of the nodule. While growth in this direction is taking 
place, the surrounding skin occasionally appears also to have 
become affected, and numerous red nodules crop out in various 
directions. In this way a large area of the skin of the chest may 
become diseased, and there is presented the condition known by 
French writers as cancer en cuirctsse. Occasionally the original 
tumor enlarges with frightful rapidity, and often with the appear- 
ance of an inflammation. The skin of the breast becomes red- 
dened and slightly cedematous, showing a well-defined outline 
(Fig. 95). This redness spreads over the whole breast, which 
becomes hard and brawny, 
and the infiltration in- 
volves the skin of the 
thorax-wall beneath the 
axilla. Such fulminating 
cases are fortunately rare. 

As the disease prog- 
resses in the mammary 
gland the glands in the 
axilla become enlarged 
and matted together, and 
they fill out the cavity of 
the axilla with a firm nod- 
ulated tumor. At this time 
there may be observed 
in the supraclavicular re- 
gion a slight fulness which 

is not to be seen on the other side. This appearance shows that 
the axillary infection has spread beneath the clavicle. From this 
point the cancer-cells follow the chain of glands which accompany 
the internal mammary artery, or they may next infect the bron- 
chial glands at the root of the lungs. 




Fig. 95. — Brawny Infiltration of Breast in Cancer. 



668 



SURGICAL PATHOLOGY AND THERAPEUTICS. 



When the tumor is very near the sternum, Volkmann has seen 
the axillary glands of the opposite side also infected. It is stated 
by Billroth and Winiwarter that glands felt in the axilla and above 
the clavicle may in some cases disappear after operation. This dis- 
appearance can only be explained on the theory that they were 
inflammatory. In the case of inflamed cancers such enlarged 
glands might be found, but so far as the writer's experience goes 
such fortunate retrograde changes are not seen. 

The infection of the lymphatic glands in the axillary and sub- 
clavian regions finally becomes so extensive that the return of the 
venous blood and lymph is retarded, and an cedematous enlargement 
of the arm results, which involves the whole limb and sometimes 
attains enormous proportions. This symptom is then a sign of 
deep-seated glandular involvement, and is a contraindication to 

operative interference unless 
for the relief of pain (Fig. 
96). There is, however, al- 
ways a tendency to degener- 
ation and absorption of the 
cancerous growth, and so far 
as this goes there is a tend- 
ency consequently to spon- 
taneous cure. The writer 
does not, however, find any 
such case reported in litera- 
ture, although Billroth men- 
tions a case of scirrhous 
cancer that had almost en- 
tirely disappeared, at the 
time of the patient's death, 
from metastatic deposits. 

Metastasis is supposed to 
occur through the lymphatic 
system in cancer, but this is 
probably not always the route 
taken by the disease. Bill- 
roth suggests that the nod- 
ules found in the lungs, the 
liver, and the kidneys reach 
those regions by embolism, 
a growth of cancer-cells in- 
vading the vein, being carried thence to the heart and through the 





Fig. 96. 



-QEdema of Arm in late stages of Cancer 
of Breast. 



CARCINOMA. 669 

pulmonary system to the various organs. He doubts whether the 
disease can be transmitted by the lymphatics through the diaphragm 
to the liver and through the posterior mediastinum to the spinal 
column. In one case seen by the writer a line of infected lymphat- 
ics led along the ribs to the spinal column and thence to the liver, 
which was completely infiltrated with cancer. In this case there 
had been no return of the disease in the axilla, but one or two 
nodules were found in the cicatrix of the breast. The liver and 
lungs are most frequently the seat of metastatic deposits. The 
pleura may be infected by direct extension of the growth from 
the primary nodule through the chest-wall. These deposits may 
also be found in the bones and in the dura mater, and more rarely 
in some other internal organ. Billroth observed an appearance of 
the disease in the other breast several times, but the experience of 
most surgeons is that metastasis to the breast is an extreme rarity. 
It is not probable that the disease ever spreads directly from one 
breast to the other. 

The average duration of life in cancer of the breast that runs its 
course untreated is, according to Gross, 28.06 months. In 536 cases 
which were operated upon, and in which the disease returned, the 
average duration of life was 38.5 months. The operation appears, 
therefore, to have had the effect of prolonging life in those cases 
for ten months. Dietrich's estimates place the prolongation of life 
at seven months. It is usually considered that after the lapse of 
three years from the date of operation the patient may be regarded 
as permanently cured if no return has been observed, the percent- 
age of recurrence after that period being exceedingly small. Gross 
found that 11.83 P er cent - of the cases in his collection met that 
requirement. A combination of the statistics of Banks, Kiister, 
and Gross, consisting of 257 cases, shows that 19.38 per cent, were 
cured. The mortality of the operation amounted in this series to 
12.06 per cent. In Dietrich's series of no cases there were 8 
deaths, or a mortality of 7.6 per cent. His percentage of cures 
was 16.2. In the series of cases operated upon by him Dennis 
estimates the cures at 25 per cent. In 71 cases operated upon 
by him there was 1 death from haemophilia. His mortality 
was, then, 1.4 per cent, or if the haemophilia case be excluded 
it was o. Bull reports 75 cases with 3 deaths and 20 cures, 
the percentage of cures being 26.6, showing an increase over pre- 
vious records. Richardson found that the mortality of all cases 
(290) operated upon at the Massachusetts General Hospital up to 
the year 1877 was 7.9 per cent. The mortality of the operations 



670 SURGICAL PATHOLOGY AND THERAPEUTICS. 

performed from 1877 to 1887 was 8.3 per cent, showing an increase 
due to the so-called "completed" operation. 

1 The completed operation, so called, implies thorough dissection 
of the axilla. It has since been found necessary to dissect off the 
fascia of the pectoralis major muscle, and many operators have 
within the last year or two removed both the pectoralis major and 
the pectoralis minor. Notwithstanding the increasing severity of 
the operation, the mortality is steadily decreasing. In the writer's 
cases there have been* but two deaths since he began to perform 
the completed operation. This series includes an amputation of 
both breasts with dissection of the axillae, in many cases the re- 
moval of the two pectoral muscles and in one case the division of 
the clavicle. It would be fair to place the mortality of the writer's 
cases at 2 per cent. ; it is probably less than that. In regard to the 
number of cures the writer is unable to give any figures, but he 
found that all those cases which passed the three-year limit proved 
to be scirrhous cancer. The writer has in several cases dissected 
the supraclavicular space : this is the almost invariable practice of 
Halstead, who also removes both pectorals. In 50 cases Halstead has 
had but 6 per cent, of local recurrences. He advises the removal of 
breast and glands in one continuous mass to avoid wound-infection. 

In regard to the question of operation in the axilla, many sur- 
geons speak of the period previous to axillary infection. Since 
the writer has been in the habit of dissecting the axilla in every 
case of operation for cancer of the breast, he has never yet found 
an axilla that had not already been infected, and in one case, 
already referred to, the operation was performed three weeks after 
the disease had first made its appearance as an extremely small 
nodule in the upper and inner quadrant. 

The diagnosis of cancer of the breast often presents great diffi- 
culties. Although a lump in the breast of a woman between forty 
and fifty years of age is cancer in 80 per cent, of the cases, there is 
a residue in which non-malignant growths occur. The commonest 
form is cyst-formation due to chronic mastitis. This cyst usually 
develops in the upper hemisphere, and it is accompanied by the 
enlargement of a few glands in the axilla. These glands, however, 
are discrete and soft, and unlike the matted glands of cancer. The 
writer finds the use of the Mixter punch most valuable in such 
cases, and in fact in all doubtful cases of cancer. The operation 
when performed with cocaine injection is painless and harmless, 
and it secures a specimen amply sufficient for microscopic diag- 



CARCINOMA. 671 

nosis. Chronic mastitis with fibrous thickening or tubercular 
abscess may be mistaken for cancer. 

There remains to be considered still one form of disease which 
is usually described as an affection of the breast, although belong- 
ing strictly to the class of carcinoma of the skin. Page? s disease 
of the nipple has been compared to an eczematous affection limited 
to the nipple and the areola, which affection eventually becomes 
malignant and may involve the whole breast. The disease is 
rarely seen before the age of forty. It may make its first appear- 
ance after a confinement or after nursing, and shows itself on or 
about the nipple as a crust which cannot easily be removed. 
Presently the skin becomes red and more or less inflamed, and the 
nipple gradually becomes retracted. The area of the disease con- 
tinues to spread, and the part becomes indurated and slightly raised 
above the level of the skin. The diseased surface gradually be- 
comes more moist and bleeds easily, and finally ulceration takes 
place, often becoming quite deep in the vicinity of the nipple. 
The disease is accompanied by itching and burning. As the carci- 
noma grows the ulceration becomes deeper and the induration 
greater, and eventually it may extend into the deeper portions of 
the breast. Glandular involvement is rare except in the latest 
stages of the disease. 

The histological changes observed in this disease have been 
studied by Paget and Porter among the earlier observers, and more 
recently by Thin, Darier, and Wickham. In the earlier stages the 
disturbance is limited, as in keratosis, chiefly to the epidermic 
layers. During the earliest period there are found an elevation 
and a thickening of the epidermis, and the cells of the rete lying 
between the papillae are more abundant, and project more deeply 
than normal into the cutis vera. The true skin is infiltrated with 
small round-cells in its upper layer, but the deeper layers appear 
to be normal. Wickham made a special study of the psorosperms 
in this disease, and at this stage found them numerous in the Mal- 
pighian layer. They appear as round or oval bodies with thick glisten- 
ing capsules, and they are situated in the protoplasm of the epithelial 
cells, pushing the nucleus to one side. When treated with alcohol 
the protoplasm of these bodies contracts, and leaves a space which 
was regarded as a vacuole in the cell. In a more advanced stage 
the epidermic cells are often wanting, and even the Malpighian 
layer is more or less destroyed, so that the papillae are covered 
chiefly by round-cells. The corium is now infiltrated with an 
inflammatory exudation. At the beginning of the cancerous stage 



672 SURGICAL PATHOLOGY AND THERAPEUTICS. 

there is found an epithelial growth invading the corium and the 
various glandular structures to be found there, such as the seba- 
ceous and sudoriparous glands and the ducts of the mammary 
gland. These ducts are eventually filled with pavement-epithelial 
cells. As these cells grow the walls of the smaller ducts give way 
and the epithelial growth invades the stroma of the gland. It pre- 
serves the type of epithelial cancer, and in that form involvement 
of the axillary glands does not take place until late in the disease. 
During the active stage of the epithelial growth the psorosperms 
have been observed by Wickham forming cyst-like structures con- 
taining a number of oval corpuscles. 

The prognosis of the disease is favorable for cancer, for the pre- 
cancerous stage may endure for many years: after the cancerous 
stage has developed the breast can be removed in time to forestall 
involvement of the axillary glands, and a permanent cure may be 
the result. 

In the early stage the part should be treated as for eczema, but 
if soothing ointments fail to heal the disease, the growth can be 
destroyed with chloride-of-zinc paste or with solid caustic potash, 
or be seared with the actual cautery. 

The ' ' nitric-acid method ' ' described by Chiene enables one to detect with 
greater accuracy the presence of cancer in an amputated breast. The breast 
should be washed in water to remove all traces of blood; it should then be 
submerged in a 5 per cent, aqueous solution of nitric acid (B. P.) for about 
ten minutes. Wash the specimen in plenty of running water, and place in 
methylated spirit for two or three minutes. Epithelial structures are turned 
an opaque white, fibrous tissue is rendered transparent, and fat is unaltered. 
The cut surface should be treated in the same manner. In this way the sur- 
geon can determine more accurately than by the naked eye whether all dis- 
ease has been removed. 

3. Carcinoma of the Uterus. 
The uterus, before all other organs, is the one most frequently 
affected with cancer. Schroeder reports that in an examination of 
26,200 cases in his gynecological clinic, cancer of the uterus was 
observed in 812, or in 3 per cent, of all cases examined. In 7881 
cases of cancer collected by Andrews, cancer of the uterus existed 
in 2308. Although affected so frequently with primary cancer, the 
uterus is more rarely the seat of metastatic cancer than any other 
organ. Cancer occurs in this organ in middle life or near the 
period of the menopause. From statistics of deaths in Vienna 
from 1862 to 1869 it is seen that deaths from cancer of the uterus 
occur most frequently from the thirty-sixth to the sixtieth year. 



CARCINOMA. 673 

It may occur in early life, but it is far more rare, though usually 
more malignant, at that period. The figures of Williams show 
that heredity does not play a very important part. In 108 cases 
investigated, malignant disease was found to have existed in the 
relatives in 23 cases, or in 21.3 per cent., but in only 8 
cases were the parents affected with cancer. The disease occurs 
most frequently in women who have borne children, particularly 
in those who have had large families. It is rare in the nulliparae, 
and when it does occur it appears chiefly in the body of the uterus. 
Among the diseases of the uterus that seem to favor the develop- 
ment of cancer may be mentioned chronic endometritis, particu- 
larly that variety which is accompanied by glandular hypertrophy. 
It seems to occur more frequently in the poor than in the rich, 
though negresses — who are particularly liable to uterine fibroids — 
are far less subject to cancer than white women. 

There are three principal seats of cancer of the uterus: it is 
found in the vaginal portion, in the cervical canal, and in the body 
of the uterus. Recent investigations seem to show that many of 
the cancers seen in the cervical canal or on the vaginal portion do 
not spring from the surface epithelium, but from the glandular 
structures in the deeper parts of the neck of the uterus, and that 
they appear sometimes in the cervix, and sometimes make their 
way out through the vaginal mucous membrane. Many of the 
papillary growths spring from this source (Ruge and Veit). 
Cancer of the neck and the cervical canal is far commoner than 
cancer of the body of the uterus. 

The cancer of the vaginal portion develops from the epithelium 
of this region, and is a pavement-cell epithelioma. It is of the 
same type as cancer of the skin. There is an abundant stroma in 
which the clusters of cells are imbedded. It may grow on one or 
both lips. It is occasionally seen developing from the surface of 
an old laceration, and very rarely it occurs in the interior of the 
uterus. The pavement-cell epithelioma, however, does not occur 
so frequently as was formerly supposed to be the case, for many of 
the cancers of this region are of the alveolar type, resembling 
more the adeno-carcinomata springing from glandular structures 
deep in the cervix. Cancer of this part of the uterus grows 
frequently as a papillary tumor, and it may assume considerable 
size, producing the so-called u cauliflower " growth. These pap- 
illary growths may have a broad basis or they may be attached 
only by a pedicle. A certain portion of these cauliflower growths 
are composed of pavement epithelium; others, however, have 
43 



674 



SURGICAL PATHOLOGY AND THERAPEUTICS. 



cylinder epithelium, and they closely resemble the villous cancer 
of the bladder (Orth). Other forms of epithelioma may be flat and 
superficial, resembling somewhat the type known as rodeiit ulcer. 
The epithelial type, or cancroid, spreads outward into the vagina; 
it is rarely seen in the interior of the uterus or the cervix, 
although it may invade the cervical canal. 

Carcinoma of the cervical canal is more of the glandular or 
alveolar type, and it is developed from the glandular structures of 
this region. The disease may develop here without showing itself 
externally before it has produced a general ulceration of the 
cervical canal. It may, however, grow upward and involve the 
cavity of the uterus, or it may grow outward into the vaginal 
portion. Eventually the cervix is destroyed, and when the disease 
is found in an advanced stage of ulceration it is difficult to decide 
from which region the cancer originally developed. 

In cancer of the body of the uterus there is presented a type 
more distinctly glandular in character, the so-called " adeno-carci- 
noma" or malignant adenoma. Here the growth spreads deeply 
into the muscular tissue of the uterus, and many of the trabecular 
of the stroma contain unstriped muscular fibres (Fig. 97). The 




Fig. 97. — Cancer of the Uterus (oc. 3, obj. A 



cells in the alveoli are cylindrical, and are often arranged around 
a central lumen as in gland acini. Near them, however, are other 
alveoli, which contain solid masses of cells. These carcinomata 
may vary from the scirrhous to the medullary type, according to 
the amount of stroma they contain. By changes in the stroma 
there may occur a mixed form of growth, such as myxo-carci- 



CARCINOMA. 675 

noma or sarco-carcinoma, according as the stroma changes to 
mucous or to sarcomatous tissue (Orth). 

As cancer of the cervix spreads the parts about become con- 
verted into one large ulcer, and the anatomical relations are lost. 
The cervix is destroyed, and the disease next involves the mucous 
membrane of the vagina, when the border of the ulcer may be 
raised, forming the margin of a crater. From this point the dis- 
ease may spread to the subserous tissue about the uterus and at the 
base of the broad ligaments and the parametrium. It also extends 
into the wall of the uterus in a horizontal line, so that the entire 
thickness of the wall is simultaneously affected. Occasionally 
there may be found an isolated nodule of cancer higher up than 
the apparent upper edge of the disease. Whether this has spread 
by lymphatic infection, or whether it is possible that multiple can- 
cer can form, seems to be undecided. The pathological fact, how- 
ever, is extremely important in its bearing upon the choice of an 
operation. A curious complication sometimes occurs owing to a 
constriction of the cervical canal: as a result of this the secretions 
of the uterus are retained, and the condition known as hydrometra 
is established. In cancer of the body of the uterus the cavity may 
become much enlarged by ulceration before the cervical canal has 
been affected. This form of the disease spreads more rapidly in 
the direction of the peritoneum. Ulceration may, however, occur 
in the cervical mucous membrane from the irritation produced by 
the discharges. The whole organ often becomes enlarged, not 
simply when the body is infiltrated with cancer, but even when 
the disease is limited to the cervix. As the disease advances the 
bladder and the rectum become involved. The bladder is the or^an 
first attacked, and a fistulous opening may eventually be established 
between the bladder and the vagina, and the ureters may likewise 
become involved in the growth. A fecal fistula is also one of the 
possible complications of the disease. Infiltration of the broad 
ligaments is often accompanied with severe pains. As the disease 
progresses even the bones of the pelvis may be attacked. When 
the disease reaches the peritoneum the intestines become glued to 
the fundus of the uterus, and during the process of ulceration the 
cavity of the uterus may open into a loop of intestine. The tubes 
and ovaries are affected only quite late in the disease. Lymphatic 
infection is found in the lumbar, retroperitoneal, and inguinal 
glands. Metastatic deposits in the large abdominal organs are 
seldom seen. 

The presence of carcinoma in the uterus is not often recognized 



676 SURGICAL PATHOLOGY AND THERAPEUTICS. 

before it has reached the stage of ulceration. The earliest symptom 
is usually hemorrhage — perhaps only a slight staining, particularly 
after unusual exertion or after the act of coitus. It may, however, 
appear in the form of profuse menstruation, or it may come on after 
the menopause as a frequently-recurring hemorrhage. Of sixty 
cases examined by Gusserow, in no less than fifty was hemorrhage 
the first symptom. 

When the ulceration becomes more extensive there is often a 
watery discharge, which later may become sero-sanguinolent. In the 
papillary form of cancer the discharge may be purulent and be mixed 
with foul fragments of sloughing tissue. Pain is often entirely 
absent. The attacks of internal pain sometimes accompanying 
the disease indicate an extension to other organs or in the direc- 
tion of the peritoneum. Irritability of the bladder or of the 
rectum is caused by the gradual involvement of these organs in 
the cancerous infiltration. More rarely there may be pruritus or 
pain in the breast or symptoms of nausea. In advanced stages of 
the disease there may be symptoms of localized peritonitis. 

A singular lack of constitutional disturbance often continues 
for a long time, but later the foul discharges may occasion sepsis 
which, combined with uraemia, may produce typhoidal symp- 
toms. With the development of the cancerous cachexia comes 
emaciation, and the patient eventually succumbs with the symp- 
toms of marasmus. The duration of the disease may vary greatly. 
Its course is usually more rapid than that of cancer of the breast, 
and the patient succumbs in most cases in from six to twelve 
months from the appearance of the first symptoms. 

Many attempts have been made to determine the nature of the 
malady from the local appearances, but the only certain way of 
settling definitely the question of diagnosis is by microscopic exam- 
ination. For this purpose fragments scraped away are almost 
useless; pieces of considerable size should only be used for this 
purpose. Frequently, however, it is possible only to obtain scrap- 
ings, particularly in cases of malignant adenoma. In this case 
the scrapings should be rolled up while fresh into a ball and hard- 
ened in alcohol. Sections can then be taken from this mass for 
examination. If there are found in these scrapings typical gland- 
ular structures, perhaps with ciliated epithelium within the tunica 
propria, and a round- or spindle-cell stroma, the surgeon has to do 
probably with hyperplasia of the mucous membrane. If, however, 
there are found irregular alveoli filled with epithelial cells or an 
anastomosing network of epithelium containing possibly epithelial 



CARCINOMA. 677 

balls and a stroma in which muscular tissue is found, the diagnosis 
of carcinoma may be made. The presence, on the one hand, of 
tubular masses of gland-like tissue, very closely packed together 
without any tunica propria or muscular tissue, is strongly sugges- 
tive of malignant disease. On the other hand, an irregular gland- 
ular growth, consisting of dilated acini or of acini filled with cells 
or papillary growth situated in a normal stroma, is not sufficiently 
typical of cancer to establish a diagnosis (Orth). 

The old operation for cancer of the uterus, consisting in local 
excision or cautery, was almost invariably followed by a prompt 
return of the disease. The modern operations show better results. 
High amputation of the cervix is not a dangerous operation, and 
it shows good results, but it is less frequently employed now that 
more radical methods have come into use. Baker reports sixteen, 
cases of high amputation with no deaths. In six the disease 
recurred, and in ten there was no recurrence at periods varying 
from two to eight years. Hofmeier performed thirty-three high 
amputations with only one death. The after-results are reported by 
him to be as good as those for total extirpation. 

The early statistics of abdominal and vaginal hysterectomy show 
a large mortality. Thus in 1885 Duncan reported 137 cases of 
abdominal hysterectomy, with 99 deaths, or a mortality of 72 per 
cent. In 276 cases of vaginal hysterectomy there were 79 deaths, 
or a mortality of 28 per cent. Sarah K. Post, in 1887, collected 722 
American cases of vaginal hysterectomy, with a mortality of 24 
per cent. Scheyron, in 1890, reported 337 vaginal hysterectomies, 
with a mortality of only 16.9 per cent. Of 854 cases of vaginal hys- 
terectomy collected by Richardson and Stone for the writer — which 
cases were operated upon between 1887 and 1892 — there was a mor- 
tality of 9.48 per cent. In 483 cases of vaginal hysterectomy col- 
lected from reports in which an attempt had been made to furnish 
results, it was found that in 53 there was no recurrence at the end 
of two years; in 26, no recurrence at the end of three years; in 14, 
no recurrence is reported at the end of four years; and in 38, no 
recurrence was reported at the end of five years. In 34 cases the 
disease recurred at the end of the first year; in 45, recurrence 
was reported at the end of the second year; and in 2 only was the 
disease known to have returned during the third year. 

4. Carcinoma of the Tongue. 
Cancer of the tongue is invariably of the pavement-epithelium 
type, or epithelioma, such as has already been described in Cancer 



678 SURGICAL PATHOLOGY AND THERAPEUTICS. 

of the Skin. The cancer springs from the epithelial layer of the 
mucous membrane, but never from the glandular apparatus of the 
tongue. 

The disease is much commoner in men than in women. In 122 
cases reported by Billroth there were 6 in which the disease was 
observed in women. In 293 cases reported by Barker there were 
46 females. In a collection of 991 cases 151 were women. Statis- 
tics show that the percentage of women as compared with men 
varies from 43 to 33 per cent. The writer remembers having seen 
the disease certainly four times in women, one of whom, at least, 
was addicted to the use of a pipe. It occurs most frequently 
between the ages of forty and sixty-five, although it is occasionally 
seen at a much earlier period, as the writer has operated at least 
once upon a man not yet thirty years of age. 

Cancer is found in all parts of the tongue, but more frequently 
in the anterior half than in the posterior half, and on the edges 
rather than on the median line or dorsum, though it is seen occa- 
sionally on the posterior portion of the tongue near the papillae 
circumvallatae and in the region of the frenum. 

Occasionally two carcinomata may be found upon the same 
tongue, both of them being primary growths. The writer has 
observed this condition in one case, both nodules developing almost 
simultaneously and at some distance from each other. There may 
also be seen secondary nodules or a diffused form of cancer in the 
tongue; which fact is of importance to remember in making the 
selection of an operation. 

In no region of the body does the origin of the disease appear 
more clearly due to previously existing irritation. The presence 
of carious teeth, the foul condition of the mouth, the eating of 
highly-spiced food, the use of alcoholic drinks, and the "rough 
eating" indulged in by men may account partly for the greater 
frequency of the disease in the male sex. All authorities agree 
that a very large proportion of the cases of cancer are preceded by 
various abnormal conditions of the surface of the tongue. These 
conditions are variously described as chronic glossitis, psoriasis, 
icthyosis, smoker's patch, leucoma, or leucokeratosis. The latter 
condition strongly resembles that which has already been studied 
in the morbid conditions of the skin preceding cancer. Leucoma 
may assume various forms, but the commonest form is a patch or 
patches of white furry membrane, which patches appear to be 
somewhat thicker than, and therefore slightly raised above, the 
surface of the surrounding membrane. The patches seen by the 



CARCINOMA. 679 

writer were very white and in striking contrast to the red mucous 
membrane. They were limited to the side of the tongue, and they 
covered the border rather than the dorsal surface. The whole sur- 
face of the tongue may be affected in this way. Associated with 
this condition are numerous fissures and small ulcers which appear 
from time to time. Warts are also liable to form in the latter stage 
of the disease, and, according to Butlin, a wart on a leucomatous 
base never gets well and always becomes cancerous. These con- 
ditions have been called the " pre-cancerous stage," and the fre- 
quency with which cancer seems to follow such conditions both on 
the skin and in the mucous membrane appears to justify the ex- 
pression. 

According to Wallenberg, leucoma — or " leucoplakia, " as it is 
often called — is caused most frequently by the irritation produced 
by the volatile and empyreumatic oils of tobacco. It may also be 
caused by disturbances in the digestive tract, with which of course 
the tongue sympathizes. Syphilis is also supposed to be a predis- 
posing cause. A section made through a leucomatous patch shows 
a growth of the epithelium of the rete mucosum both upward and 
downward. According to Butlin, the papillae are obliterated, but 
in a section made by Gannet, a drawing of which is before the 
writer, the interpapillary epithelium seems to be elongated down- 
ward. There is a thickening also of the epidermic layer. The 
papillary layer is infiltrated with round-cells. Such a condition 
strongly resembles that seen in keratosis senilis, and it could with 
propriety be called "keratosis linguae." Leucoma is almost un- 
known in persons under twenty years of age. It appears rarely to 
begin in persons over sixty, and it seldom attacks women (Butlin). 

The writer has seen but few cases of leucoma — one in a lady on whose 
tongue it first appeared in youth, and remained in the shape of several large 
brilliant white patches until old age, when it disappeared ; in another case, 
a man forty-three years of age, the tongue had been troublesome from child- 
hood ; the mucous membrane was sensitive and easily irritated, and it was 
prone to inflammatory conditions, during which small ulcers appeared. 
At the age of thirty-four typical leucoma appeared, situated for the most 
part on the right side of the tongue. Three years later the patches 
enlarged and a warty growth formed in the centre. Three years after this 
the writer removed with the knife the largest patch, which was about the 
size of a silver half-dollar. This operation was performed in June, 1891. 
In October, 1891, a small epithelial growth of an apparently malignant 
nature appeared on the opposite side of the tongue. This growth was 
removed, and it was found to be typical cancer. In December a similar 
growth was removed from the tip of the tongue. In April, 1892, both 
growths having reappeared, a large portion of the left side and the tip 



680 SURGICAL PATHOLOGY AND THERAPEUTICS. 

of the tongue was removed by a wedge-shaped incision. The disease never 
returned in the tongue, but six months afterward a glandular enlargement 
was observed under the left jaw, and the patient died two months later. The 
growth was found to be typical carcinoma. 

In the case above alluded to the writer had an opportunity of 
observing the earliest stages of the cancerous growth, as it was 
shown to him but a few weeks after it had made its appearance. It 
even then had an unmistakably cancerous aspect. There was a 
distinct infiltration of the tissues of the tongue, and the growth 
was surrounded by the pearly rim so characteristic of epithelial 
disease. 

When fully developed the cancerous growth usually breaks 
down in the centre and presents itself as an ulcer with indurated 
and elevated margins. Such ulceration occurs in cancers situated 
on the side of the tongue and subjected to friction against the edges 
of the teeth. It may appear also on the side of the tongue as a 
nodulated mass in the form of a rosette, without any tendency to 
ulceration. As the disease grows the fold of mucous membrane 
extending to the jaw becomes involved, and the tongue is bound 
down by the contractions that occur to the floor of the mouth. 
When these ulcers are situated near the base of the tongue, 
the anterior pillar of the palate, and eventually the tonsil and 
the wall of the pharynx, become involved. 

Less frequently the disease begins as a nodule in the substance 
of the tongue, which nodule slowly enlarges, and finally shows 
itself above the surface. More rarely still the disease appears to 
originate beneath the floor of the mouth, and never comes to the 
surface, but it is felt as a hard, indurated mass beneath the chin. 
The tongue is so drawn down as to be deeply indented at some one 
point, and speech, and even swallowing, are often materially 
affected. In one such case that the writer has under observation 
the patient is greatly distressed by a constant flow of saliva. The 
enlargement of the lymphatic glands occurs at varying periods 
during the progress of the disease. Usually the glands do not 
appear to be affected until several months after the first appearance 
of the disease in the tongue. 

Many cases are on record where the tongue has been removed, 
in which event there has been no subsequent manifestation of the 
disease. It is, however, not an uncommon occurrence to find a 
return of the disease, if such an expression may be used, in the 
lymphatic glands, while the tongue remains healthy. In such a 
case it is clear that the gland in question was already affected at 



CARCINOMA. 68 1 

the time of the operation, but that it was too small to be felt. 
Kocher mentions a case in which glandular infection occurred in 
five weeks, and the writer has seen one where the glands were 
infected equally early in the disease. The writer is so strongly 
impressed with the danger of leaving such an infected gland that 
he should not be contented to operate upon a case of cancer of the 
tongue without exploring the glandular region. He has, however, 
followed one case for two years in which half of the tongue was 
excised through the mouth and no glands were sought for. There 
was at the last report no evidence of disease, but such a result is 
hardly sufficient to authorize a repetition of the operation in the 
light of the usual experience. 

The most frequent seat of glandular infection is the floor of the 
mouth and the submaxillary region. A gland may be felt in front 
of the sterno-mastoid muscle and at the side of the thyroid carti- 
lage. The glands of the neck are quite as likely to be involved 
as are the glands of the axilla in cancer of the breast, and the 
writer has no doubt that the small percentage of cures reported is 
due to the fact that ' ' completed operations ' ' are not so frequently 
performed as they should be. Occasionally there is seen an exten- 
sive enlargement of the submaxillary and cervical glands, with 
little or no primary disease of the tongue. In a case which came 
under the writer's observation the upper triangle of the neck was 
so filled with enlarged glands as to form a tumor of considerable 
size. The tongue presented the appearance of the so-called " fern- 
leaf" pattern, but there was only slight induration, and it was 
difficult to say exactly where the primary lesion was situated. 

As the disease progresses in the mouth the ulceration increases, 
and the interior of the mouth becomes converted into a foul crater. 
The pain, which at first is usually slight, becomes severe, and it 
radiates in the direction of the ear, and a great deal of acute pain 
is often experienced in the later stages of the disease. The glands 
of the neck become enormously enlarged, and they form a tumor 
filling out the side of the neck from the jaw to the clavicle. The 
trachea is often pressed over under the opposite ear, and the rings 
can be felt beneath the skin; but difficulty of breathing is rarely 
experienced, although it may be impossible for the patient to 
swallow solid food. Metastatic deposits are said to be compara- 
tively rare, but they may be seen in the lungs, the liver, and the 
kidneys. Death may occur from hemorrhage or from exhaustion. 

The diseases most likely to be mistaken for cancer are simple 
ulcers formed by the friction of the sharp edge of a displaced 



682 SURGICAL PATHOLOGY AND THERAPEUTICS. 

tooth, syphilis, and tubercle. In the case of the simple ulcer the 
position of the lesion, when the tongue is in its natural position, 
usually indicates sufficiently clearly the origin of the affection. 
The removal of the tooth is promptly followed by healing of the 
ulcer. In syphilis there is usually an induration of the substance 
of the tongue rather than a new growth of tissue: the disease is 
said to be found more frequently upon the median line than 
cancer. Tuberculosis of the tongue occurs as a chronic inflamma- 
tory process, and it appears as an ulcer with a more or less ill- 
defined inflammatory infiltration of the adjacent parts, whereas 
cancer does not produce an inflammation of the surrounding 
tissues. The line between the healthy structures and the new 
growth is therefore usually well marked. 

In all uncertain cases — and they are numerous — a fragment 
should be removed for microscopical examination, and this removal 
can be effected in no better way than by the Mixter punch. 

Cancer of the tongue runs a comparatively acute course, the 
duration of life varying from six to eighteen months from the first 
appearance of the disease. 

The operations for removing the tongue vary greatly, and they 
may in general be classified under three heads. Formerly a large 
number of cases were operated upon by the ecraseur^ owing to the 
fear of hemorrhage, and many operators still prefer this method, 
but it is rapidly going out of use. Whitehead's method of remov- 
ing the tongue through the mouth with scissors has replaced the 
older operation. It consists in a rapid excision of one-half or the 
whole of the tongue with the scissors, care being taken to keep the 
mouth well open during the operation. Hemorrhage is prevented 
by the use of haemostatic forceps, which seize the lingual arteries 
either before or as they are divided. In the third group belong those 
operations which contemplate an incision for the purpose of expos- 
ing the submaxillary and cervical glands, and the removal of the 
tongue either through the mouth or through the incision thus 
made. The submental incision, which enables the operator to 
remove the tongue through the floor of the mouth, is a useful 
method in case of cancer near the frenum or in the apex of the 
tongue. The submaxillary incision exposes the upper triangle of 
the neck, and enables the operator to remove the infected glands in 
this region before the mouth is opened, and the tongue is drawn 
through the wound. This method is sometimes called " Kocher's 
operation," and it is frequently preceded by tracheotomy in order 
that the wound in the mouth may be treated antiseptically. 



CARCINOMA. 683 

The operation preferred by the writer consists in an incision 
directly downward from the corner of the month to the lower edge 
of the jaw, and thence backward to the angle of the jaw. After 
the cheek is reflected the jaw is divided at a point opposite the 
disease. A vertical incision downward from the wound exposes 
the infected gland region of the neck. Through a wound thus 
made the whole infected area may be removed in one continuous 
mass. 

The mortality of operations upon the tongue for cancer is some- 
what difficult to obtain, owing to the great variety of operations 
and to the varying degrees of severity of the disease. The causes 
of death are usually bronchitis, pneumonia, or gangrene of the 
lung. The German expression schluck-pneumonie suggests the 
infective nature of the process. Death rarely occurs from hemor- 
rhage or from shock. In 139 cases reported by Whitehead there 
were 20 deaths, showing a mortality of 14. 3 per cent. Separating 
the cases where the tongue alone was removed from those in which 
the glands and the jaw were involved, it is found that in the for- 
mer cases the mortality was only 4.5 per cent., whereas in the 
more complicated operations where the glands were involved the 
mortality ran as high as 77 per cent., and where a portion of the 
jaw was also involved as high as 57 per cent. 

In a series of 58 cases reported by Kocher, belonging to the class 
of "glandular" or " completed " operations, in which the most 
strict antiseptic precautions were observed, the mortality was only 
10.3 per cent. These results are better even than those following 
the use of the ecraseur. A series of 40 cases reported by Barker 
operated upon in this way gives a mortality of 12.5 per cent. Bill- 
roth's clinic gives a mortality of 10. 1 per cent, in 148 cases. This 
mortality is a marked diminution from that in his earlier cases, 
which at one time was as high as 25 per cent. 

The results of treatment in this disease cannot be said to be 
encouraging. In the series of 148 cases just alluded to there were 
only 10 cases that remained well at periods varying from fourteen 
months to eight years. On an average the patients died one year 
after the operation from a return of the disease. In 38 cases in 
which reports were obtained by Kocher it was found that the dis- 
ease had returned in 25. The earliest return appeared within 
seven months, and in one case the disease did not appear until ten 
years after the operation. In the 13 cases in which there was no 
return reported, 5 were found well at the end of seven, eight, ten, 
and twelve years, respectively. In Barker's series of 170 cases 



684 SURGICAL PATHOLOGY AND THERAPEUTICS. 

there were less than five who were well three years after the ope- 
ration; and in Butlin's 70 cases there were but 6 cases of cure on 
the three-years' limit. Richardson obtained 13 answers from 20 
cases operated upon at the Massachusetts General Hospital. Of 
these cases 11 were dead, and of the 2 living cases it is uncertain 
whether one of them was cancer. 

It will be seen that the best results thus far reported have been 
obtained after Kocher's operation. The very small percentage 
of permanent cures reported by nearly all surgeons may in part be 
accounted for by the imperfect nature of the method of operating 
employed. Few surgeons are content at the present time to remove 
the breast without a dissection of the axilla, but the number of 
those who attempt a dissection of the strategic points in the neck 
in cancer of the tongue is yet small. In the writer's opinion the 
whole neighborhood of the infected region should carefully be 
explored for disease, and in a majority of cases it is advisable to 
perform temporary section of the jaw in order to expose thoroughly 
the seat of the trouble. It is only by such radical measures that 
it can be hoped to reduce the fearful mortality of cancer of the 
tongue. 

5. Carcinoma of the (Esophagus. 
Carcinoma is one of the most frequent forms of disease of the 
oesophagus. It belongs to the pavement-epithelium type of car- 
cinoma, and on microscopic examination epidermic balls are found 
here and there among the clusters of epithelial cells. It develops 
from the epithelium of the mucous membrane or from the ducts 
of the mucous glands. Colloid cancer of the oesophagus is said to 
be extremely rare. Butlin refers to a scirrhous type in which the 
progress of the disease is unusually slow. The disease is said to 
occur oftener in men than in women, although the writer has seen 
it in about an equal number of each sex. Of 510 cases analyzed by 
Newman, 108 were women and 402 were men. It is most frequent- 
ly found in persons over forty years of age. Mackenzie in a study 
of ico cases found 92 in which the patients were over the age of 
forty. The seat of the disease varies greatly. Rindfleisch places 
it in the middle third of the oesophagus, particularly at the point 
where the left bronchus crosses the oesophagus. Mackenzie found 
the disease in more than half the cases in the upper half of the 
oesophagus. Petri and Zenker, however, found 63.8 per cent, of 
the cases in the lower third. Newman states that the commonest 
spot in his experience is behind the cricoid cartilage. The writer 



CARCINOMA. 685 

found it usually below the level of the cricoid cartilage or on a 
level with the upper edge of the sternum: in one case he saw it at 
the junction of the pharynx and oesophagus. The disease usually 
encircles the tube and causes a firm constriction. When the oesoph- 
agus is laid open the disease appears as an ulcer with elevated and 
everted edges. The width of the carcinomatous ring varies from 
2 to 8 cm., but it may rarely be much more extensive. 

As the disease progresses the ulceration becomes more extensive, 
and perforation may take place into the trachea or the bronchi, the 
posterior mediastinum, the pleura, the pericardium, or the blood- 
vessels. Perforation of the trachea is a not infrequent complica- 
tion, and it can be recognized by the presence of a muco-purulent 
expectoration containing particles of food. The growth may press 
upon the recurrent laryngeal and pneumogastric nerves. Meta- 
static deposits are found in the adjacent lymphatic glands, and not 
infrequently in the lungs, the liver, and the kidneys. 

The first symptom of the disease is, in the majority of cases, 
difficulty in swallowing. On questioning the patient a history of 
loss of flesh during the previous six months may usually be ob- 
tained. As the disease progresses a tumor can be felt in the region 
of the neck or the cervical glands are perceptibly enlarged. The 
presence of a cough shows that the disease has begun to infringe 
upon or to involve the tracheal wall. The passage of a bougie 
w r ill usually settle the diagnosis, for strictures from any other 
source except from swallowing corrosive liquids are extremely rare. 

The treatment of cancerous strictures formerly consisted in the 
frequent passage of bougies, but this method is liable to be fol- 
lowed by perforation of the softened tissue. Symonds devised a 
method of oesophageal tubage which is far superior. Symonds' 
tubes are about 4 inches in length, and have a funnel-shaped open- 
ing which permits them to be introduced and left in the stricture; a 
ligature attached to the end of the tube emerges from the mouth 
and is fastened to the ear. Mixter devised an ingenious method 
of sounding the narrow strictures and of dilating them, and he has 
improved Symonds' method of introducing the tubes. These 
tubes can be worn for several days at a time w 7 ith great comfort. 
This method supersedes largely the formation of a gastric fistula. 

Gastrostomy, as originally performed, established a fistula 
through which the patient could easily be fed. The operation 
provided no means of preventing the escape of the contents of the 
stomach through the fistulous opening. The cough with which 
patients in the advanced stage of cancer of the oesophagus are 



686 SURGICAL PATHOLOGY AND THERAPEUTICS. 

afflicted often favors leakage through the fistula. Several ope- 
rations have been devised to overcome this difficulty. Von Hacker 
makes the fistula through the left rectus muscle, so as to secure a 
sphincteric action from the tonic contraction of its fibres around 
the extruded portion of the stomach-wall. Witzel aims to combine 
a sphincter-like action of the muscles of the abdominal wall with 
a valvular fistula. The fistula passes through both the rectus and 
the transversalis muscles, whose fibres, running at right angles to 
each other, may be expected to contract still more efficiently than 
the rectus muscle alone. The second feature of this operation is 
the unfolding of a tube in the wall of the stomach, which is stitched 
over the tube so as to form an oblique canal. This method is said 
efficiently to overcome the tendency to leakage from the stomach. 
A third method, described by Meyer as the Ssabanejew-Frank 
method, consists in drawing out a loop or cone on the stomach- 
wall through the ordinary oblique incision, and passing it under a 
bridge of skin to a point above the border of the ribs, where it is 
fastened and opened. This operation has not as yet had an exten- 
sive trial, but Meyer, in a review of these various methods, looks 
upon it as the coming operation in cases of malignant oesophageal 
stenosis. The writer has succeeded in establishing a srastric fistula 
with perfect valvular action on a dog by the following operation : 
A fold of the anterior wall of the stomach is pinched up and 
stitched one and a half inches higher up on the surface of the 
organ. If an incision is made into the stomach just below the line 
of suture, a double fold of mucous membrane will be found hang- 
ing over the inner opening of the cut. In the stomach of Alexis 
St. Martin a similar fold of mucous membrane covered the internal 
orifice of the fistula. According to Knie, the average duration of 
life in thirty-five cases successfully operated upon was one hun- 
dred and twenty-five days. Tracheotomy may be necessary on 
account of oedema of the larynx or pressure upon the recurrent 
laryngeal nerve. CEsophagectomy was performed in 1877 by 
Czerny for a small growth in the oesophagus, the lower segment 
of which was united to the external wound. Ashurst collected 
twelve cases of ©esophagectomy with eight deaths. If the growth 
could be discovered early enough, such an operation might be con- 
templated with a view to a radical cure of the disease. 

6. Carcinoma of the Larynx. 
Cancer of the larynx appears usually as a pavement-cell carci- 
noma; rarely an encephaloid or a scirrhous form exists in the 



CARCINOMA. 687 

larynx. Cancers of this region are divided into intrinsic and 
extrinsic. Intrinsic cancer includes growths originating from the 
vocal cords, the ventricular bands, and the ventricles. Extrinsic 
cancer is situated upon the epiglottis, the ary-epiglottic folds, and 
the interarytenoid region. 

Cancer of the larynx is a disease of advanced life, 50 per cent, 
of the cases occurring between the ages of fifty and seventy. Males 
are more liable to the disease than females. The abuse of tobacco 
and strong alcoholic drink, prolonged residence in humid, cold 
climates, as well as respiration of gases or of vapors of an irri- 
tating nature, are predisposing causes (Morgan). 

Intrinsic cancer has at first the appearance of a wart-like 
growth taking its origin somewhere in the middle or the upper 
portion of the larynx, from the vocal cords, or the margin of 
the ventricle. Ulceration takes place at an early period, and it 
infiltrates the surrounding parts, involving the cartilages and 
eventually spreading beyond the limits of the organ. The lym- 
phatics are infected ultimately, but only to a limited extent 
Metastatic deposits are probably exceedingly rare, as death oc- 
curs in the majority of cases from changes produced by the local 
conditions. 

Extrinsic caiicer originates in the epiglottis or the ary-epiglottic 
folds or anywhere on the upper margin of the larynx. From this 
point it spreads to the surrounding parts, and it may involve the 
pharynx, the tongue, the tonsils, and the palate. The lymphatic 
glands are infected early in the disease. 

The earliest symptom of this disease is hoarseness; later there 
may be difficulty of breathing and of swallowing. Pain, which at 
first is dull, may later be of a sharp, cutting character, and it extends 
to the ear, cheek, and neck of the affected side. There is cough, 
with a more or less foul, purulent expectoration. 

An early diagnosis of the disease is of the greatest importance, 
for there may be sarcoma as well as cancer in the larynx, in addi- 
tion to the many benign forms of growth, and tubercular and syphi- 
litic ulceration may exist within the larynx. The removal of a 
fragment for microscopical examination should, according to New- 
man, not be done until it is decided to operate immediately if the 
growth prove to be carcinoma, as the growth often becomes more 
malignant after such an operation. 

The prognosis is unfavprable in all forms of cancer of the larynx, 
but it is much worse in extrinsic cancer. In intrinsic cancer the 
disease progresses slowly and death may not occur for several years. 



688 SURGICAL PATHOLOGY AND THERAPEUTICS. 

Patients affected with extrinsic cancer die usually at the end of a 
year or eighteen months. The treatment may be palliative or be 
operative. Under the former heading comes tracheotomy, which 
often relieves many of the most distressing symptoms of this dis- 
ease. The principal operations are thyrotomy and unilateral or 
complete laryngectomy. The mortality of total extirpation of the 
larynx has decreased somewhat within the last ten years, but it is 
still quite high. 

In 121 cases compiled by Newman there were 41 deaths, or a mor- 
tality of 33.88 per cent. In 55 partial extirpations there were 16 
deaths, or a mortality of 29.09 per cent. The results of operation 
in cases of intrinsic cancer show that after total extirpation of the 
larynx 16 per cent, of the cases remained well at the end of three 
years, and in partial extirpation the percentage of cases of intrinsic 
cancer remaining well after three years was 17.40. The number 
of operations is now exceedingly large, and many have been per- 
formed in America. In carefully-selected cases, such as that 
recently reported by Monks, where the disease was confined to the 
vocal cord and the patient remained well in active work eighteen 
months after the operation, it is reasonable to hope that a perma- 
nent cure may be effected. 



7. Carcinoma of the Stomach. 

Cancer of the stomach is one of the commonest forms of carci- 
noma. It takes its origin from the cells of the gastric follicle, and 
as the disease develops it perforates the muscular layer and then 
spreads rapidly. The commonest variety is the cylinder-cell cancer, 
which may appear both as a medullary and as a scirrhous form, 
and colloid cancer is also occasionally seen. The disease attacks 
men slightly oftener than women. It is rarely seen before the age 
of thirty, three-fourths of all cases occurring between the ages of 
forty and seventy. The most frequent seat of the disease is at the 
pyloric orifice. Welch analyzed the reports of 1300 cases, and 
found the pyloric region the seat of the disease in 60.8 per cent. 
The growth shows a tendency to break down and ulcerate. At 
times this tendency is so great that only a small margin of cancer 
remains, as in rodent ulcer of the skin. At other times the 
growth is very exuberant. Metastatic deposits in the lymphatic 
glands and the abdominal organs are frequent accompaniments of 
the disease. 

The principal symptoms are pain in the epigastrium, with 



CARCINOMA. 689 

symptoms of dyspepsia, vomiting, the development of a percepti- 
ble tumor, and emaciation. 

The disease may be regarded as incurable, but attempts have 
been made during the last decade to remove the growth by resec- 
tion of the pylorus. Billroth, the originator of this operation, 
reports 29 operations with 16 deaths. Of the 13 who survived the 
operation, 5 died within ten months after the operation; 2 lived 
over one year; 1 lived one and a half years; 1 lived two and a half 
years; and 1 lived five and a quarter years. Only 2 patients 
remained well at the time of the report, but in 1 the operation had 
been performed only four and a half months before, and in the 
other two and a half months before. The total number of cases 
reported at the Berlin Congress was 56, with a mortality of 48.2 
per cent. Among the most recent reports are those of Czerny, 
who gives 12 operations with 5 deaths: 2 were living in complete 
health fifteen and twenty-six months after the operation. The other 
5 died two, seven, ten, fifteen, and eighteen months, respectively, 
after the operation, with symptoms of a return of the disease. 

8. Carcinoma of the Intestines. 

Carcinoma of the Intestines. — The most frequent seats of car- 
cinoma of the intestines are at the ileo-csecal valve, the descend- 
ing colon, and the sigmoid flexure. Cancer may, however, occa- 
sionally be seen in the small intestine. Of 37 cases collected by 
Butlin, 32 were in the large intestine and 3 in the small intestine, 
the seat of 2 being uncertain. In 4 cases the disease was in the 
ascending colon; in 3, in the transverse colon; in 7, in the 
descending colon; and in 9, in the sigmoid flexure. The variety 
usually seen is the cylinder-cell carcinoma, which may at times 
assume the medullary or the scirrhous type. Colloid cancer is also 
found in this locality. Ulceration begins early, and cicatricial 
contraction accompanies it, so that the disease may appear as a 
narrow fibrous stricture with little if any new formation. At 
other times considerable length of the bowel may be affected. As 
the disease progresses the muscular coat is perforated and the 
peritoneal coat becomes infiltrated. As a result of this infection,, 
adhesions occur to adjacent peritoneal surfaces, and the diseased gut 
becomes so bound down that an operation for resection or one for 
intestinal anastomosis is rendered exceedingly difficult: sometimes 
it is impossible to perform either operation. Death occurs usually 
as the result of chronic obstruction of the bowels. According to< 
Butlin, the duration of the disease is short. From the beginning 

44 



690 SURGICAL PATHOLOGY AND THERAPEUTICS. 

of the symptoms to the time of death the period varies from six 
to eighteen months. The disease attacks males and females about 
equally. It occurs generally after the age of forty years. 

Operative statistics collected by Weir and Butlin show a high 
mortality. In 37 patients reported by Butlin on whom the opera- 
tion was performed, 18 died shortly afterward. In only one 
instance among those who survived the operation was there a 
patient still well at the end of a year. Czerny reports 10 cases of 
resection for malignant growths — 4 at the caecum, 2 at the sig- 
moid flexure, 3 in the transverse colon, and 1 in the descending 
colon. In 3 cases an adjacent coil of intestine was involved; 1 
was a medullary cancer, 1 was a papillary growth, and 4 were 
adeno-carcinomata; of the latter four, 3 were of the scirrhous type; 
3 were cases of colloid cancer, and 1 case proved to be an alveolar 
sarcoma which appeared five years after the removal of an ovarian 
sarcoma. This patient remained well six years after the resection 
of the intestine. Of the cases, 5 recovered from the operation and 
5 died. Of the five recoveries, 1 died six months afterward from 
local recurrence, and 4 were alive six, fifteen, nineteen months, and 
six years respectively after the operation. Of the patients, 6 were 
women and 4 were men. The men all died from the effects of 
the operation. The average age was forty-five years. Czerny 
regards the most favorable cases for operation those of the scir- 
rhous type, which cause stricture early and thus lead to operation. 

9. Carcinoma of the Rectum. 

Carcinoma when found at the anus is of the pavement-cell 
variety, and when growing from the mucous membrane it appears 
as a cylinder-cell carcinoma. There are, therefore, in this locality 
both types of the so-called "epithelioma." The pavement-cell 
form, which takes its origin in the cutaneous coverings of the 
anus, begins as a warty or papillary growth that breaks down 
early and ulcerates. It is not unlike cancer of the lip in its early 
stages. The surrounding parts are more or less hard and infil- 
trated, and the edges of the ulcer are elevated and sharply defined. 
The growth spreads inward and involves the mucous membrane, 
and it invades also the external integument, involving the peri- 
neum or the commissure of the vagina and the labia in women. 

The cylinder-cell carcinoma (Fig. 98), which develops from the 
follicles of Iyieberkuhn, begins as a more or less exuberant growth, 
which soon breaks down and develops into a crateriform ulcer 
involving more or less of the circumference of the bowel. This 



CARCINOMA. 



691 



growth is found some little distance within the rectum, and it is 
often difficult for the exploring ringer to reach its upper margin. 



ivsiwS^&SSS? 




. — Cancer of the Rectum (oc. 3. obj. A.). 



The cells are arranged in acini, and they have a strikingly glandu- 
lar appearance, closely resembling that seen in cancer of the uterus 
(Fig. 99). It is therefore often called " adeno-carcinoma n or malig- 
nant adenoma. This is the common- 
est variety of cancer of the rectum. 

Cancer occurs also in the medul- 
lary form, but more rarely. It is 
exceedingly malignant, and it soon 
infiltrates the walls of the rectum, 
converting the latter into a rigid 
tube and gluing it to surrounding 
parts. Scirrhous cancer is said to 
occur high up near the sigmoid flex- 
ure or in the neighborhood of the 
prostate. It infiltrates the submu- 
cous tissues, and the mucous mem- 
brane over it for a time appears 
healthy. It grows slowly and causes 
annular stricture, or it is felt as a 
hard nodule in the wall of the rectum. Colloid cancer appears 
as a diffuse infiltration of the mucous membrane that spreads to 
the deeper parts. It is, however, a rare form of cancer in this 
region. Villous cancer is occasionally also seen. 




Fig. 99. — Cancer of the Rectum, 
showing cylinder-cells (oc. 3 obj. D.). 



692 SURGICAL PATHOLOGY AND THERAPEUTICS. 

Cancer of the rectum occurs usually in middle life or in old age. 
There are, however, exceptions to this rule, cases having been 
reported in youth and even in childhood. In a collection of 107 
cases, Kelsey found 50 cases in males and 57 in females. 

As ordinarily seen, cancer of the rectum forms a large crateri- 
form ulcer, with raised edges, encircling the bowel, and it is situ- 
ated two to three inches from the margin of the anus. As it grows 
it spreads chiefly to the deeper parts. As the surrounding layers 
become involved there is great destruction of tissue; contraction 
consequently takes place, and a long, narrow stricture forms, the 
walls of which are made up of the cancerous growth. In the 
female the vagina and the uterus become attached to the growth, 
and in the male the prostate and the bladder are invaded. The 
growth may extend also to the sacrum. As the walls of the adja- 
cent organs give way before the advance of the disease, fistulse are 
established and fseces may be discharged in the urine or urine may 
flow into the rectum. 

Cancer of the rectum remains for some time a localized disease. 
In 47 autopsies reported by Iversen there were no metastases in 21. 
After a certain period of time the lymphatic glands in the peri- 
rectal fat become enlarged, and the infection spreads along the 
pelvis into the abdominal glands. When the disease is situated 
near the anus the glands of the groin may become involved, and, 
according to Czerny, this form of cancer is much more likely to 
recur after operation. 

The duration of the disease is seldom more than two years, 
although instances have been recorded in which the symptoms 
have existed for as many as five or six years. Patients sometimes 
die, however, within a few weeks or months of the first appear- 
ance of the symptoms of rectal affection (Butlin). 

The early symptoms of the disease are often mistaken for hem- 
orrhoids. The breaking down of the new growth gives rise to a 
bloody or muco-purulent discharge which is mistaken for diar- 
rhoea. Later, the constriction causes apparent constipation, with 
intercurrent loose discharges or tape-like stools. Accompanying 
this condition there may be a certain amount of ill-defined, colicky 
pain. As the growth increases there is a sense of weight or deep- 
seated pain in the pelvis or the back. In the more rapid-growing 
forms of cancer the pain may become excruciating as the new 
growth forces its way into the tissues. Later the symptoms of 
obstruction are observed. Cachexia in the later stages of the dis- 
ease is very marked. Cachexia is caused partly by the disease and 



CARCINOMA. 693 

partly by the septic absorption from the bowel and the secondary 
affection of other organs. 

The operation that was formerly employed for a radical cure of 
the disease was known as the u Lisfranc" operation, and it consisted 
in an excision of the bowel from below. Statistics compiled up to 
1881 show a high mortality, varying from 31 to 58 per cent, in the 
hands of different surgeons. During the next ten years the im- 
proved methods produced a considerable reduction in the death- 
rate. Thorndike estimates the mortality of the operations of vari- 
ous kinds done during this period in a selected series as low as 16. 1 
per cent. Butlin collected 100 cases, including part of both periods, 
with a mortality of 35 per cent. Of the 65 patients who survived 
the operation, all were not subsequently heard from, but 13 cases 
were reported alive and well for at least two years after the opera- 
tion. Iversen in an analysis of 247 cases of all kinds of operations 
found in 70 patients who survived the operation (but who died 
subsequently) that there was a local recurrence in 42, and in 32 
cases that were still living there were 6 with local recurrence 
of the disease. 

Kraske's method was first described in 1885: it consists in a pos- 
terior incision with resection of the coccyx and a portion of the 
sacrum. There are other operations of a similar nature, but dif- 
fering in the amount of bone resected. This operation, although 
it is more severe than the earlier method, does not appear to be 
much more dangerous. A collection of 102 cases operated upon 
in this way gives a mortality of 21.5 per cent., though Thorndike' s 
collection of cases gives a mortality of only 14.7 per cent. 

It is early yet to determine the merits of the modern operation 
as a curative measure. Arnd, in a collection of 98 cases operated 
upon by various methods, reported 24 "cures" (time-limit not 
stated), and of these he found 15 had been operated upon by the 
modern method. Of 39 cases operated upon by Albert, 3 were 
well one year after operation, 2 were well two years after ope- 
ration, 1 had passed the three-year limit, and 1 was well four years 
after operation. 

The number of cures by any method is not yet known to be 
large. The disease is, however, in many cases exceedingly slow 
in its course, and if cases are carefully selected for operation it 
seems probable that the future will show an increased percentage 
of cures. 



694 SURGICAL PATHOLOGY AND THERAPEUTICS. 

10. Carcinoma of the Bladder. 

Cancer may grow from the walls of the bladder or from the 
prostate gland. Cancers growing from the latter organ are in no 
way to be distinguished clinically from those of other regions of 
the bladder, and they form a large proportion of the malignant 
growths in the vesical cavity. 

The precise origin of carcinoma at the neck of the bladder is 
indeed difficult to determine, and even those carcinomata situated 
more posteriorly at the base of the bladder are uncertain in their 
origin, as the middle lobe of the prostate may have prolongations 
extending some distance into the walls of the bladder, and the 
disease may be found to spring from these glandular bodies, as in 
a case reported by Marchand. The epithelium of the acini of the 
prostate is a short cylinder-epithelium, and in the deeper more 
spongy portions of the prostate it is cubical. A small- cell carci- 
noma with a glandular arrangement of the cells in the alveoli is 
strongly suggestive of prostatic origin. There are, however, forms 
of carcinoma that spring from the bladder-wall directly, although 
Klebs claims that such do not exist. Bode found that in 30 cases 
of cancer of the bladder 14 were in women. 

Orth describes the villous cancer as the commonest form. 
There may be a benign papilloma appearing as a villous tumor, 
and also a villous cancer. In the papilloma are found very long 
fimbriated processes composed of a connective tissue in which run 
blood-vessels covered by several layers of columnar cells. In the 
villous cancer are found similar villi, and in the base of the tumor 
at the point of origin of the broad villi and also in the bladder- 
wall are found alveoli containing cancer-cells. The villi are, how- 
ever, as Krister shows, merely an accidental feature of these 
growths, and indicate nothing as to the microscopical character of 
the tumor. 

Cancers of the bladder-wall spring from the deeper layers of the 
epithelium and rarely from the epithelium of the mucous glands. 

The commonest form of cancer of the bladder, according to 
Krister, is that composed of squamous and pear-shaped cells, a 
polymorphous type with cells resembling those of the bladder- wall. 
There is an abundant connective-tissue stroma which produces a 
scirrhous type of cancer. The medullary form is much less fre- 
quent. Sometimes the cells assume the pavement-epithelium 
form, producing pavement-cell carcinoma or epithelioma, such as 
is seen in the skin. In these cases well-marked epithelial nests 



CARCINOMA. 695 

or epidermic balls may be found. Colloid cancer may also occur 
here. This condition may involve the whole or only a part of 
the growth. All these varieties appear as rounded, more or less 
flattened elevations in the mucous membrane. The membrane 
may run smoothly over the growth, or it may be infiltrated, or, 
finally, papillary growths may develop on the surface of the tumor. 
A papilloma may precede the development of a cancer for several 
years, and Kiister suggests that the irritation produced by the pull 
of the tumor upon the mucous membrane during urination may be 
a source of irritation which gives rise to the cancerous growth. 
The conditions resemble those in the skin where warty growths 
precede epithelioma. 

As the cancer grows ulceration takes place, and the villi, if 
present, disappear. The growth penetrates the muscular wall, 
which becomes thickened, and it finally reaches the peritoneum, 
causing the bladder to become adherent to adjacent organs, some 
of which may eventually become involved in the disease. There 
is a remarkable tendency, however, of these carcinomata to remain 
local; which fact Watson attributes to the lack of connection of 
the larger lymphatic channels with the mucous membrane. The 
inguinal glands may occasionally be infected. The lungs and the 
pleura are the most frequent seats of metastatic deposits. As the 
carcinoma breaks down and ulcerates, the urine may become 
exceedingly foul, and be mixed with blood, bacteria, and frag- 
ments of tissue. As a result of the irritation thus produced the 
kidneys become diseased, and patients affected with this disease 
are said to die most frequently of pyelitis. Secondary cancer of 
the bladder has been observed, although it is extremely rare. In 
a case reported by Targett the disease was found in the muscular 
layer. 

The most characteristic and commonest symptom of bladder- 
tumors is hsematuria. The symptoms of catarrhal inflamma- 
tion come later, and a microscopical examination may lead to a 
diagnosis of the disease. Pain is not always present, but at times 
the emptying of the bladder is accompanied by severe cramp. At 
first there is slight constitutional disturbance, but as the disease 
progresses there may be emaciation, and later symptoms of cachexia 
or of kidney complications may arise. 

The course of the disease in isolated cases may be extraordi- 
narily slow. Budor reports one case in which the patient died 
twenty-four years after the first symptoms, and Guyon reports a 
case of eighteen years' duration. 



696 SURGICAL PATHOLOGY AXD THERAPEUTICS. 

The opera:: :ment of cancer of the bladder consists in 

suprapubic or perineal cystotomy, with curetting and cautery of 
the growth, which is of course but a palliative measure, or in an 
attempt to perform a radical cure. The operation devised for this 
purpose consists in excision of a portion of the bladder-wall or in 
extirpation of the bladder. Marsh mentions five cases of resection 
of a portion of the bladder-wall. Of these cases, two only could 
be said to have recovered from the effects of the operation, one 
living twelve months and one living four years. Marsh also adds 
a sixth case of his own, which was fatal. These results show a 
mortality of 66 per cent., and not one radical cure. 

Extirpation of the bladder has been performed in four cases, 
according to Watson, with three recoveries, but it does not appear 
that the operation was performed for cancer. 

In a collection of eight cases made by Stone, four were found to 
have died of the operation, giving a mortality of 50 per cent. One 
case, in which two-thirds of the bladder was removed, lived one 
month, dying of v ' asthma. " In another case, in which one-third 
of the bladder was removed, the wound healed in fifty-five days. 
Recurrence of the disease took place in six months, the patient 
dying at the end of a year. One patient lived four years, the 
disease reappearing two years after the operation. Fenwick reports 
nine cases of operation by twisting with forceps and cutting with 
scissors. In one case the disease returned in three months and the 
patient died. In one case the growth was removed a second time, 
and in another two subsequent operations were performed. Baker 
operated upon a woman through the vagina, cutting out the growth 
with scissors. Three months later the patient left the hospital in 
good condition. 

n. Carcinoma of the Kidney. 

The commonest form of cancer of the kidney is the medullary; 
scirrhous cancer is also seen, but less frequently. Colloid cancer 
of the kidney is rare. The disease is most frequently seen after 
middle life, but it is found also in very young children, and a few 
cases of congenital cancer of the kidney have been reported. The 
disease occurs twice or three times as often in men as in women. 
Among children the difference in sex is not so marked. 

Cancer occurs in the kidney in an infiltrated form or as a nod- 
ular growth. In the infiltrated form the kidney is somewhat 
enlarged, and the cortical portion is found thickened, particularly 
at certain points corresponding with nodular enlargements on the 



CARCINOMA. 697 

surface. These points are not sharply-defined foci, but they are 
caused by a greater development of the disease there. They have 
a grayish medullary appearance on section. Under the microscope 
the cancer-cells are seen crowding the uriniferous tubules, which 
are very irregularly distended. The cancer-cells are distinguished 
from the normal epithelium by their large vesicular nucleus. At 
some points these cells can be seen in the cortical portions of the 
kidney, and it is probable that they develop from the epithelium 
of these portions of the organ as well as in the deeper structures. 

The nodular cancer, which develops as a distinct nodule often 
separated from the rest of the kidney by a capsule, many attain a 
considerable size. The remainder of the kidney in such cases is 
flattened out against the side of the tumor. The tubules may be 
seen in the diseased portion, but they are much elongated and con- 
stricted. The cortical portion of the kidney is often seen still 
partially preserved in the periphery of the tumor. 

These large tumors undergo many retrograde changes, such as 
fatty degeneration and necrosis; also cystic degeneration, and occa- 
sionally calcification. They are often separated into lobules by 
broad bands of fibrous tissue. The trabeculse which surround the 
alveoli are often very delicate, and they seem to consist almost 
solely of blood-vessels. Such growths are necessarily highly vas- 
cular (Orth). There is occasionally seen adeno-carcinoma of the 
kidney strongly resembling adenoma, and this form may assume 
the villous type. 

The lymphatic glands behind the peritoneum and in front of 
the spine are affected early in the disease. The results of opera- 
tions upon the kidney for cancer are not encouraging. In fourteen 
cases of nephrectomy compiled by Gross the operation was very 
fatal, giving a mortality of 71.42 per cent. Death was caused 
either by uraemia, by shock, or by peritonitis. Of the four survi- 
vors, two died of secondary growths at the expiration, respectively, 
of forty-four days and two months, and the remaining two were 
alive at the end, respectively, of two months and thirteen months. 
Gross regards the disease as one which should be excluded from 
the category of cases for which nephrectomy should be performed. 
Both Butlin and Greig Smith speak unfavorably of the operation. 

Fenger recently reported a case of adeno-carcinoma of the kid- 
ney the size of an tgg^ for which he performed lumbar nephrec- 
tomy successfully. The patient was alive and well two and a 
half years after operation. Fenger quotes a case of Israel who 
diagnosticated a carcinoma the size of a cherry and operated, 



698 SURGICAL PATHOLOGY AND THERAPEUTICS. 

obtaining a radical cure; that is, according to the three-year 
limit. 

12. Carcinoma of the Testicle. 

Carcinoma testis occurs in the medullary form in most cases. 
Scirrhous and colloid carcinomas are also occasionally seen. In no 
case has the disease been observed before the age of twenty. In 37 
cases collected by Kocher it was found in 29 between the ages of 
twenty and forty. In about one-fourth of the cases the same 
author found that the disease followed trauma. The cancer-cells 
develop first in the convoluted tubes from a proliferation of the 
seminal cells. The tubes nearest the centre of the organ are usu- 
ally the first affected, the upper portion of the testicle remaining 
intact or being involved later in the disease. The rete is also 
affected secondarily. 

In the scirrhous form there is a large development of connective 
tissue, and sometimes of hyaline cartilage and bone. On section 
the growth appears as a smooth surface, on which are fibres run- 
ning in various directions without any evidence of normal tissue. 

Medullary carcinoma appears as a grayish nodular tumor with 
a slimy surface. The tumor may often be quite large, and may con- 
tain many foci of broken-down tissue, and it often attains a large size. 

In many cases of cancer of the testicle there are a large number 
of cysts (cysto-carcinoma). Secondary growths are often felt in the 
iliac fossa, and the lymphatic glands are enlarged along the spine, 
sometimes as high as the kidneys. The skin of the scrotum may 
be involved in many cases. Eventually metastatic deposits occur 
in the liver and lungs, and with the extension of the disease 
cachexia becomes marked. In consequence of the enlargement of 
the lymphatic glands pressure may take place upon the vena cava 
and the feet may become cedematous. The duration of the disease 
appears to be about two years. 

Many cases of permanent cure are reported after removal of the 
testis, but it is in most of the cases quite uncertain whether the 
disease was cancer or sarcoma. 

Winiwarter found in twelve cases only one in which there was 
no return of the disease two years and seven months after the ope- 
ration. Kocher reports six cases in which a reliable microscopic 
examination had been made. Of these patients all were alive and 
well at periods varying from one to ten and a half years. 

Of the few methods of curing cancer by medication which have 
been brought forward from time to time, there are none which have 



CARCINOMA. 699 

stood the test of practice. In view of the interest which has been 
taken in Koch's method of treating tuberculosis, it may be worth 
while to notice a similar method of treating cancer that has been 
recently brought to notice by Adamkiewicz. He advances peculiar 
views as to the nature of cancer-cells, regarding them all as pro- 
tozoa, which, though they resemble epithelium, are not epithelial 
cells. Implanted into the brains of rabbits, they are found to pos- 
sess the power to migrate into the surrounding tissues, where some 
of them are destroyed and some grow and form new foci of cancer- 
cells. He also found that when fragments of cancer are thus 
implanted they produce an inflammatory reaction which does not 
take place when fragments of healthy tissue from the living body 
are substituted. If the fragments of cancer are dipped for a few 
minutes in a 3 per cent, solution of carbolic acid or are subjected 
to the action of boiling water for one or two seconds before inplan- 
tation, no inflammatory reaction takes place. Adamkiewicz con- 
cludes, therefore, that there is a toxic property in the cancer-cell, 
and that it is due to the action of this substance that the healthy 
tissues melt away before the advance of cancer. 

This substance he calls " cancroin," and he obtains it in solu- 
tion by treating minute fragments of cancer (cut up finely) with 
distilled water. The mass is then rubbed up in a mortar and 
filtered. A slightly opalescent and alkaline fluid is thus obtained. 
Such a fluid, if injected into rabbits subcutaneously, is found to 
act as a deadly poison. Adamkiewicz obtained a similar substance 
from the muscle and skin of fresh cadavers by a similar method of 
preparation, which substance was found to resemble closely neurin. 
The filtrate obtained from a watery extract of fresh cadaver tissue 
is a clear yellowish fluid of alkaline reaction and smelling like 
alkaline urine. 

Cancroin injected subcutaneously into cancerous growth sets up 
inflammatory reaction, and it gradually produces a disappearance 
of the cancer. Before injection this alkaline fluid is neutralized 
with citric acid. A 25 per cent, watery solution is then saturated 
with carbolic acid and is diluted with an equal quantity of water. 
This preparation is called u Concentration I. " Concentration II. 
is diluted to one-half the strength, and Concentration III. is diluted 
to one-quarter the strength, of No. I. The author begins with a 
subcutaneous injection of No. III. at some point not too remote 
from the growth. The results of these experiments are not suffi- 
ciently encouraging to authorize a general adoption of the method. 

In a personal communication from Adamkiewicz to the writer 



yoo SURGICAL PATHOLOGY AND THERAPEUTICS. 

he states that, although he has had thus far but little success with 
the method, he nevertheless regards it as an important advance in 
the treatment of cancer. 

The post-operative treatment of cancer is now regarded by 
many surgeons as a feature in the management of every case in 
which an operation has been performed for malignant disease. 
Among the drugs most frequently used for this purpose is 
arsenic. Wight recommends the administration of the bromide 
of arsenic in doses of from ^ to ^ grain after meals, and the 
carbonate of lime before meals in 5- to 10-grain doses in the 
tincture of calumba. Clemens' solution is a convenient form of 
administering the bromide of arsenic. It may be given in doses 
of 2 to 3 drops three times a day after meals. Wight advises that 
its use should be continued for from six to twelve months. In 
several cases of inoperable cancer he has found the progress of the 
disease delayed and considerable relief to pain. 

Roswell Park employs arsenic in the following combination, 
which contains the haloid salts of mercury, arsenic, and gold: It 
is administered in 10-minim doses, each of which contains -^ of a 
grain of bromide of arsenic, ^- of a grain of bromide of gold, and 
the y^-q of a grain of bichloride of mercury. The doses may be 
increased up to the physiological limit, and the use of the drug 
should be continued for months after the operation. It may also 
be given in inoperable cases. (See Appendix.) 

Pyoktanin was first recommended by Mosetig-Moorhof. In his 
original experiments anilin trichlorate was used, but in large doses 
this had a poisonous effect. Pyoktanin possesses the advantage of 
not being poisonous to the system. His object was to attack the 
nuclei of the proliferating cancer-cells, and then to arrest the 
growth of the tumor. The affinity which the anilin dyes have for 
nuclei first suggested to him that this staining process might be 
brought about upon the living cells, and their vitality be thus 
impaired. The agent is injected subcutaneously, so as to come in 
contact with the diseased cells. 

The pathogenic cells are dyed by pyoktanin in the living body. The 
cell-stain is not apparent at first. Mosetig accounts for the absence of 
coloring by the presence in the cancer-cells of a chemical substance which 
is able to reduce the anilin dyes in such a way that they lose their color. 
When the tumor has been extirpated and sections have been prepared from 
it for microscopical examination, exposure to the oxygen of the air brings 
out the blue stain. 

It may be used in solutions of the strength of 1 : 1000, 1 : 500, 
and 1 : 300. It is probable that much stronger solutions may be 



CARCINOMA. 701 

used with safety. Mosetig-Moorhof has given as much as 6 
grammes of a 1 : 300 solution without ill effects. The injection 
should be repeated every two or three days. The whole mass of 
the tumor should gradually become impregnated with the stain- 
ing fluid. Park has seen undoubted benefit from the use of 
pyoktanin, although as yet in no case a cure. He gives it in 
solutions of the strength of 1 : 1000 to 1 : 400. He also uses 
methyl-blue chemically pure internally, giving it usually in con- 
nection with the extracts of nux vomica and cinchona. Meyer 
reports one or two cases by other observers that appear to have 
been cured by this treatment, but in his own experience, which 
has been large, there has been no cure, although great improve- 
ment has been obtained in several cases. 

Mosetig-Moorhof reports a case of cancer of the gall-bladder 
which had been opened for gall-stone. A pencil of methyl-violet 
was introduced every two to four days, and 0.6 Gr. methyl-blue was 
given by the mouth daily. The general condition of the patient 
improved, the growth, a villous cancer, largely disappeared, and 
the incision contracted to a small fistulous opening. This surgeon 
reports several cases of sarcoma and carcinoma in which, although 
permanent cure had not been effected, there was considerable 
improvement in the condition of the patient. (See Appendix.) 

The use of Chian turpentine, Southall's solution, or Metcalf's 
emulsion is occasionally followed by some improvement in the 
ulceration which accompanies the growth of cancer. These 
preparations are usually given in doses of a teaspoonful three 
times a day, and are continued for three months. The writer 
has given this remedy a thorough trial, and in but one case 
only, a case of cancer of the tongue, did there appear to be any 
result whatever. In this case the ulceration in the mouth healed, 
but the progress of the disease continued as before. 

Although the therapeutic results of the treatment of cancer are 
most discouraging, the disease is not one in which the patient should 
be abandoned hopelessly to his fate. Both mental and physical relief 
has been obtained by the measures already mentioned: much may 
also be accomplished by general measures. Park recommends 
efforts to improve elimination in every possible way from the skin, 
kidneys and the alimentary canal. 

In cases of internal cancer the utmost care should be given to 
the condition of the digestive organs, and special rules should be 
laid down for the management of cases according to the locality in 
which the disease is situated. 



XXX. SARCOMA. 

The term l< sarcoma," derived from adoc (flesh), was first used to 
denote all kinds of fleshy growths. There was also supposed to be 
a resemblance between the fibre of sarcoma — particularly of certain 
forms — and the fibre :: muscular tissue This group of tumors is 
composed of the embryonic types of connective tissue, and in this 
respect it differs from most other tumors, which correspond in their 
structure to the rally-developed tissues of the body. Its embryonic 
nature is shown in the large numbers of cells of which it is com- 
posed. These cells vary greatly in their character in different 
varieties of sarcoma, but they are all types found in embryonic 
connective tissue. The round- and spindle-shaped cells are found 
not only in these tumors, but also in certain stages of development 
:: thetrh tissue. cmd tls: ;.t certrhn ;:rt::ls in the trrccess :•: rercir 
in a healing wound. The giant-cell is also characteristic of the 
embryonic structure of the medulla of bone, and it is seen both in 
bone and in connective tissue during that period of a morbid pro- 
cess when the embryonic type reasserts itself. There is this im- 
portant difference, however, between the cells of inflammation 
and repair and those of sarcoma: in that the former have but a 
temporary existence, whereas the latter tend to indefinite growth; 
it is this tendency which gives to sarcoma its malignant cha- 
racter. 

These cells tire characteristic :::t :my in their shtme. but also 
in their disposition in an intercellular substance, as is the case with 
all cells of the group of connective substances This intercellular 
substance may at times be very scanty and difficult t: see. and it is 
then composed either of delicate fibres or of granular material; at 
: ther times it may be more distinctly fibrous. It may also be com- 
posed of a transparent mucous substance, such as is found in the 
foetal cord. Occasionally it forms between the cells a delicate net- 
work which resembles the reticulum of the lymphatic glands. As 
the intercellular substance increases in quantity the cells diminish 
in number, and with this change is found a corresponding diminu- 
tion in the maliornancv of the growth. 

By adhering very strictly to these lines in deciding upon the 
- : 



SARCOMA. 703 

microscopic diagnosis of sarcoma the surgeon is not likely to mis- 
take it for a tumor arising from a different form of tissue, such as 
carcinoma, wherein the epithelial cells are in direct contact with 
one another, being cemented together, and are enclosed in alveolar 
spaces by the stroma. The combined forms of sarcoma and car- 
cinoma mentioned by Virchow are, in the light of these dis- 
tinctions, no longer recognized. These growths originate from 
different germinal layers in the embryo, and they remain for 
ever after distinct. The endothelial growths in this respect 
come nearer to sarcoma, and they are so classified by some 
authors, although they have been placed among the carci- 
nomata. 

Sarcoma is usually a very vascular tumor, and in some cases the 
blood-vessels are developed to such a degree that the tumor actually 
pulsates. Microscopically, the walls of the vessel appear inti- 
mately connected with the new growth, and many of the walls 
seem to be made up almost solely of cells, being in many cases 
simply blood-spaces in the centre of the growth. Interesting in 
this connection is a growth regarded by some observers as allied to 
sarcoma, and described by Billroth as cylindroma, which is com- 
posed of columnar masses of endothelial cells in a more or less 
transparent matrix, and which is supposed to be formed from a 
growth of the endothelium of the blood-vessels, whose walls 
have undergone hyaline degeneration. Sarcoma seems closely 
associated with the blood-vessels, except that class known as 
lymphosarcoma, which is as intimately associated with the lymph- 
atics. 

The classification and definition which Virchow laid down for 
the sarcomata is substantially maintained to-day, although certain 
tumors that were formerly placed in this category have been 
dropped from the list. The tumor seen in actinomycosis was at 
one time supposed to be sarcomatous, until eventually its true 
nature was detected. It is possible that future discoveries may still 
further limit the number of tumors which are now regarded as 
sarcoma. 

At present little is known about the etiology of this class of 
tumors. Cohnheim's theory that these growths depend upon a dis- 
turbance in the embryonic structure from which they spring has 
something suggestive in it in the light of the fact that sarcoma is 
often seen in infancy, or that it is even congenital in the sense that 
it springs from moles or other growths of congenital origin. Con- 
genital sarcoma is comparatively rare. As a rule, sarcoma appears 



704 SURGICAL PATHOLOGY AND THERAPEUTICS. 

first at a much more mature period of life. In ioo cases of sar- 
coma collected by Stort 56 were men and 40 were women. The 
ages of the majority of the cases ranged from forty to seventy years. 
It appears to be of traumatic origin, and it has been known to fol- 
low blows upon the testis, the mamma, and the bones, and accord- 
ing to Nasse trauma is more frequently the cause of sarcoma than 
of any other tumor. Any source of irritation may serve apparently 
as a cause. Sarcoma appears occasionally in scars, and it may fol- 
low chronic inflammatory processes. Hesse reports that the lungs 
of the cobalt-miners of Schneeberg are invariably affected with 
lymphosarcoma, although other people in the vicinity do not have 
the disease. 

Recent investigations show that the so-called " organisms of a cellular 
nature ' ' are found in the cells of sarcoma as well as in those of carcinoma. 
Pawlowsky, following a suggestion of Steinhaus, studied the cells of sar- 
coma, and found organisms which he regarded as sporozoa (microsporidia). 
These structures are seen in the protoplasm of the cells, and they contain 
spherical or oval spores. They react differently from the other cells to stain- 
ing fluids. He traces the spore into the cell, where it is surrounded by a ring 
of protoplasm which forms a capsule around the multiplying spores. Event- 
ually, the capsules burst, and the spores are set free in the intercellular sub- 
stance of the tumor, whence they reach other cells. The sarcoma-cells begin 
to grow and to multiply under the influence of the parasite. Pawlowsky 
thinks it probable that in the melanotic sarcomata these parasites obtain 
their nourishment from the constituents of the blood, and that they stand in 
close relations to the haemoglobin of the red blood-corpuscles. So far as his 
own experience goes, these organisms are less frequently seen in the cells of 
sarcoma than in those of carcinoma. 

Sarcomata may grow wherever connective tissue exists, but 
they are more frequently seen in the skin, the fascia, the inter- 
muscular connective tissue, the bones, the periosteum, the brain, 
the ovaries, and the testicle. The classification it is customary to 
adopt at present is that based chiefly upon the character of the 
cells of which the tumor is composed. 

The round-cell sarcoma is composed either of small or of large 
cells. The small round-cell sarcoma consists of round cells con- 
taining but little protoplasm, and of a globular or an oval nucleus. 
The intercellular substance is slight in quantity, and it is granular 
or is faintly fibrillated. The vessels are numerous, and they have 
very thin walls. This tissue closely resembles that seen in granu- 
lations. Such tumors are found in the skin, the testicles, and the 
ovaries (Ziegler). When the intercellular substance forms a retic- 
ulum of stellate cells anastomosing by numerous prolongations, 
the round cells are found in large numbers in the meshes of this 



SARCOMA. 



70S 




Fig. 100. — Alveolar Sarcoma (oc 



r a 2 oilim.). 



reticulum, and there is found an arrangement such as is present in 
the lymphatic glands. Such 
a tissue is found in lympho- 
sarcoma. 

The la roc round-cell sarco- 
ma is composed of cells con- 
taining an abundant proto- 
plasm and of a large vesicular 
oval nucleus. These cells are 
so large that they look like 
epithelium, and the stroma is 
so slight that the cells appear 
to be in contact with one an- 
other. Running through the 
growth, however, are tra- 
becular of connective tissue, 
forming alveoli from the walls 

of which, spring the delicate fibres which run between the cells. 
The tissue is very vascular, containing large vessels giving off fine 
capillaries that penetrate the alveoli in the delicate stroma. This 
tumor is called " alveolar sarcoma" (Fig. 100). Such an arrange- 
ment of cells and stroma corresponds very closely with that found 
in carcinoma, and it is only by careful preparation that the differ- 
ence between the two kinds of growth can be detected. If a thin 
section taken from an alveolar sarcoma is shaken up with water in 
a test-tube or is brushed with a camel' s-hair pencil, many of the 
cells drop out and the connective-tissue stroma is made apparent. 
This is not a very common form of sarcoma. It is found in the 
cutis, the muscle, the bone, and the testicle. 

The spindle-cell sarcoma (Fig. 101), however, is the commonest 
form. It is composed of long spindle-cells, of varying size, closely 
packed together. The cells lie with their broad surfaces in con- 
tact with one another, and they are arranged in bundles running 
in various directions, so that in a section one sees longitudinal and 
cross-sections of such bundles (sarcoma fasciculatum). There is 
but a small amount of intercellular substance, and blood-vessels 
are seen in the axes of the bundles of cells. These cells are often 
so closely packed together that their form cannot be made out dis- 
tinctly, and the nuclei seem to lie very close to one another. The 
grain of the tumor is, however, characteristic, and on picking the 
cells apart or on brushing them the spindle-cells with their long 
prolongations are seen. These cells are not always fusiform, but 
45 



706 



SURGICAL PATHOLOGY AND THERAPEUTICS. 



they may have several prolongations, giving thein quite an irreg- 
ular shape. This variety of sarcoma is usually a good deal firmer 




Fig. ioi. — Spindle-cell Sarcoma (oc. 3, obj. D.). 

in consistency, and is less malignant, than the round-cell sarcoma. 
Medullary forms occur occasionally. The prognosis of these 
tumors depends, however, greatly upon their locality. 

The giant-cell sarcoma, or myeloid sarcoma, is characterized by 

the presence of cells 
of a great variety of 
shapes and sizes, but 
more particularly of 
the giant- cell, and a 
mass of protoplasm 
containing a large 
'^ number of nuclei 
(Fig. 102). The nu- 
clei are large and 






S 



l'tt%&W^~tt'&&*$ refractive, and are 
Isi^*^ ~^>%A % *' usuall v massed near 










Fig. 102.— Giant-cell Sarcoma (oc. 3, obj. D.). 



the centre of the cell, 
and the protoplasm 
is composed of a thick, 
finely-granular mate- 
rial which has a yel- 



SARCOMA. 707 

lowish or a brownish tinge. These cells are often quite numerous; 
at other times they are found only in certain portions of the growth. 
The other cells of which the tumor is composed are polymorphous. 
There are found spindle-, stellate, club-shaped, and round cells. The 
amount of intercellular substance is usually exceedingly small; con- 
sequently, it is a soft and pulpy tumor which often has a brownish 
tinge. Similar giant-cells are seen in the marrow of embryonic 
bone, but they are not so large. These tumors are almost always 
seen in the marrow of bone, but giant-cells are found also in peri- 
osteal sarcomata. 

Melanosarcoma is characterized by the presence of a dark pig- 
ment in the cells. Any of the forms of sarcoma may be pigmented, 
but melanosarcoma usually contains round or spindle-cells. The 
pigment-granules are found in the body of the cells, but never in 
the nucleus. The pigment is arranged in many cells so as to dis- 
tend the cells and alter their shape, the pigment-granules appearing 
as large, dark, globular masses, the clear nucleus being crowded 
into one corner of the cell. All the cells are not pigmented, and 
the younger portions of the tumor may have no pigment whatever. 

These granules are not to be mistaken for blood-pigment, which, 
seen in "multiple-pigment sarcoma," may have been absorbed from 
a blood-clot the result of hemorrhage. In such a case pigment- 
granules are also to be found between the cells. Virchow believes 
that the pigment is formed in the cells, and this view is most gen- 
erally accepted ; others have supposed that the pigment is formed 
directly from the blood. These tumors grow in the choroid coat of 
the eye and in the skin, especially on the foot and the hand ; they 
have also been seen in the lymphatic glands. Melanosarcoma is one 
of the most malignant varieties of tumor known, and metastatic 
deposits are found in the liver and in other internal organs, many 
of these metastases being unpigmented and presenting white nodules. 

Sarcoma may also be classified according to the changes observed 
in the intercellular substance. When there is a large amount of 
fibrous stroma, which occasionally occurs in spindle-cell sarcoma, 
it is called a "fibrosarcoma." In myxosarcoma the intercellular 
substance is clear and homogeneous, like that seen in myxoma ; 
the cells may be round, stellate, or fusiform. Such tumors are 
seen in the intermuscular septa and also in connection with sar- 
coma of bone. Gliosarcoma is a round-cell growth with an inter- 
cellular substance similar to that seen in the neuroglia. It is found 
in the central nervous system and also in the retina. It is a soft, 
white medullary growth, and is usually very malignant. Angio- 



708 SURGICAL PATHOLOGY AND THERAPEUTICS, 

sarcoma has been denned as an angioma with sarcomatous growth 
of the vessel-wall. The sarcoma-cells form in columnar masses, 
apparently in the perivascular spaces, and each column of cells 
contains a blood-vessel in its centre. The cells have a distinctly 
endothelial character, which brings it close to the class of endothe- 
liomata. These columnar masses of cells form coils which may 
anastomose freely with one another. The tumor may be more or 
less diffuse in the membranes of the brain or the peritoneum, or it 
may be nodular. It may be found in the brain, the nerves, the 
testicle, the lymphatic glands, the breast, the skin, and the bones. 
The tumor is very malignant, and the metastatic deposits have the 
same general character. 

Although sarcoma seems much more isolated from the adjacent 
tissues than carcinoma, and it is in many cases surrounded by a 
sort of capsule, a histological examination shows that the cells have 
invaded the surrounding tissues much more deeply than the micro- 
scopic appearances would lead one to believe. The cells not only 
rapidly proliferate, usually by mitosis, but it is probable that many 
of them also possess the power of amoeboid movement, and in this 
way detached foci may be found in the neighborhood of a tumor. 
For these reasons sarcoma has a strong tendency to recur locally 
after removal. These tumors have the power also to produce 
metastatic deposits, which in some cases may be so small and so 
numerous that the term "sarcomatosis" has been devised to express 
this peculiar condition. Metastasis does not occur, however, until 
a late period in the history of the disease, and local return of sar- 
coma may take place several times after operation before general- 
ization of the grow r th occurs. 

The metastatic growths take place along the course of the blood- 
vessels rather than in the lymphatics, although in the case of sar- 
coma of the bones the lymphatic glands may become involved. 
Councilman points out the closer relation of these growths to the 
blood-vessels, showing that it is by no means rare to find a sarcoma 
growing directly into a large vein, and that it may extend in this 
way for a long distance as a fleshy polypus moving freely in the 
blood-stream. As one would suppose, metastases are most com- 
monly found in the lungs, and next in order of frequency come the 
spleen, the kidneys, and the liver. 

Sarcoma may undergo retrograde changes during its period of 
growth, the most frequent being fatty degeneration of the cells. 
The most cellular and actively-growing sarcomata seem to possess 
this tendency. The sudden diminution in size or the disappear- 



SARCOMA. 709 

ance of sarcoma as the result of treatment by arsenic or through 
the action of erysipelas is in many cases to be explained in this way. 
M neons degeneration may also occur, and as the result of these changes 
cysts may develop in the tumor. Portions of the tumor often break 
down, owing to rupture of the softened walls of the blood-vessels ; 
consequently extravasations of blood are frequently seen. 

Sarcoma has in its early history a period during which it is far 
less malignant than in the later stages. During this period the 
tumor seems to remain stationary. The change to a more malig- 
nant growth may take place suddenly or gradually. The clini- 
cal significance of a sarcoma depends not only upon the nature 
of its tissue, but also upon the locality in which it is situated. 
The gliosarcoma, although confined to one locality, presents a 
condition of grave importance, owing to its relation to the cen- 
tral nervous system. The more rich in cells and the smaller the 
cells, the more rapid is the growth of the tumor. 

The various localities in which the disease grows will next be 
studied. 

1. Sarcoma of Skin. 

Sarcoma of skin occurs quite frequently, although not nearly so 
often as cancer. It may occur primarily, but also as the result of 
metastasis. Sarcoma develops quite often from warts and moles, 
which for a long time after adult life has been reached remain 
unchanged, and eventually, as the result of irritation through fric- 
tion or injury, change into sarcoma. It may also develop after 
trauma, or it may grow from granulation tissue or from a scar. 
Sarcoma may be congenital, and Babes reports a case of sarcoma 
the size of a dollar which was removed from the foot of a new-born 
child. The commonest period of life to see sarcoma of the skin is 
from thirty-five to fifty years. The disease may develop from the 
superficial or the deep layers of the skin or from the subcutaneous 
cellular tissue. In the latter case the skin is affected secondarily, 
and on section one can often see the sarcoma-cells pressing their 
way to the surface through the columnse adiposae. 

According to Babes, many of the sarcomata of the skin spring 
from the walls of the blood-vessels and are of endothelial origin. 
According to Winiwarter, sarcomata grow from the connective- 
tissue structures, from the walls of the blood-vessels and lymphatic 
walls, and from the sheaths of the nerves. The forms generally 
seen here are the spindle-cell sarcoma, the myxosarcoma, the 
alveolar sarcoma, and the melanosarcoma. The small round-cell 



yio SURGICAL PATHOLOGY AND THERAPEUTICS. 

sarcoma is comparatively rare. The superficial form appears on 
the surface as a sarcomatous wart, which may eventually attain 
considerable size, retaining a nodulated or a papillary appearance. 

The course of the disease is slow at first. There is often a 
period, perhaps of several years, during which the tumor bears the 
reputation of being benign. Then a change comes suddenly, and 
it is evident that the growth is sarcomatous. Even then the 
growth may be slow and may extend over several years. A 
sarcoma sometimes develops, however, with great rapidity. The 
adjacent portions of the skin may become affected, and eventually 
metastatic deposits are found in the internal organs. 

Sarcoma of the subcutaneous tissue is usually more distinctly 
defined as to its limits, and it may attain considerable size before 
any metastasis takes place. 

The superficial papillary sarcoma contains either round-cells or 
spindle-cells. It may also consist of alveolar sarcoma tissue. As 
it develops from some old-standing wart-like structure of the skin, 
it assumes a fungous growth. 

Sarcomatous ulcers, seen not infrequently upon the lower 
extremities, contain usually a variety of cell-forms. Congenital 
sarcoma appears as a circumscribed, hard, round growth of doughy 
consistency and of a bluish color. It is either a spindle-cell 
sarcoma or a myxosarcoma, and it recurs rapidly after removal. 
The papillae are often greatly enlarged in the affected portion of 
the skin (Winiwarter). Sarcoma may be multiple, and the 
tumors, often found in great numbers, vary considerably in size, 
but they are usually small. They are either subcutaneous or they 
infiltrate the skin, appearing as reddish nodules. They are either 
round-cell or alveolar sarcomas. They may also contain spindle- 
cells, and they are often very vascular. Death occurs from 
cachexia at the end of two or three years. 

Melanosarcoma generally originates from a pigmented mole or 
it may occur in previously healthy skin. It is often found on the 
hands or the feet. It is not uncommon to find it springing from 
the sole of the foot as if it had been produced by some injury. 
Hutchinson describes a form of " melanotic whitlow" which ap- 
pears to be connected at first with disease of the toe-nail. The 
nail falls off, and there is found a sarcomatous growth which later 
assumes a most malignant character. Pigmentation may occur in 
all forms of sarcoma, whether round-cell, spindle-cell, or alveolar 
sarcoma. The tumor when first seen may not be larger than a 
pea, but it may finally grow to be as large as the fist. The pig- 



SARCOMA. 7 'ii 

ment-granules are found principally in the protoplasm of the cells, 
but they are seen also in the deep layers of the rete mucosuin, and 
the pigmentation may affect the hair-follicles. The walls of the 
blood-vessels and the capillaries contain pigment, and pigment- 
granules may also be found in the subcutaneous tissue. Wickham 
L,egg describes the case of a man fifty-four years of age in whom 
there was a diffuse pigmentation of the skin of the face, from 
which metastatic deposits eventually took place. The lymphatic 
glands are affected early in the disease, and all the internal organs, 
including the meninges, and even the brain itself, are found to 
contain metastatic growths. The duration of the disease seldom 
exceeds eighteen months to two years. 

Multiple-pigment sarcoma differs from the melanosarcoma in 
that the pigment is apparently not obtained from the same source 
as in melanosarcoma, but is the result of hemorrhages which 
cause the deposit of blood-pigment. Some of this pigment is 
found in the cells and some in the intercellular substance. Micro- 
scopically, these tumors consist of small round cells or of spindle- 
cells, and are very vascular. The disease begins in the corium, 
and it later involves the papillary layer and the subcutaneous cel- 
lular tissue. In the papillae are seen numerous extravasations of 
blood that have occurred as the result of laceration of the capillary 
walls. The walls of the vessels may also show evidences of cell- 
growth and pigmentation (Winiwarter). This variety of sarcoma 
does not originate in a pigmented mole, but is first seen on the 
palms or the backs of the hands or on the soles of the feet. Here 
the nodules occur in groups, perhaps on all four extremities, and 
they gradually spread toward the trunk. They begin at first as small 
bluish spots which are painless, but which often itch badly. Later, 
the nodules appear, which at first are quite small, but eventually 
they may increase to the size of a hen's &gg. The progress of the 
disease is very gradual, and at the end of two or three years it may 
have involved the trunk and have reached the face. The whole 
cutaneous surface is by this time covered with nodules varying from 
the size of a pea to that of a hen's egg^ which nodules are of a 
brownish or of a bluish-red color, and are more or less painful, but 
are rarely ulcerated. In one-fourth of the cases nodules of infiltra- 
tion are found on the glans penis, the prepuce, and the scrotum. 
There is also a characteristic elephantiasis-like thickening of the 
fingers and hands and of the legs and feet, so that the fingers 
are stiff and distorted and the patient walks and stands only 
with difficulty. 



712 SURGICAL PATHOLOGY AXD THERAPEUTICS. 

The lymphatics are only moderately affected. Many of the 
nodules undergo retrograde changes, and after some desquamation 
of the epidermis over them they disappear and leave behind a dark 
pigmented cicatricial depression. Many undergo atrophy in the cen- 
tre, while the periphery remains as an indurated wall. As the disease 
advances the mucous membranes become affected. Dark bluish- 
red patches, diffuse infiltrations, or little nodules arise on the gums, 
the palate, or the uvula, and the tonsils become swollen. The 
patients begin to have fever; bloody diarrhoea and haemoptysis 
make their appearance; the liver and spleen become enlarged; and 
death is preceded by the symptoms of general marasmus. 

Metastatic deposits are found in the lungs, the heart, the liver, 
the spleen, and the intestine, particularly in the descending colon 
'Kaposi). The age at which this disease occurs varies greatly, 
although the majority of cases have been of persons in middle life. 

The prognosis is most unfavorable, although an occasional 
recovery is recorded. An interesting feature of the disease is the 
spontaneous disappearance of many of the nodules. 

2. Sarcoma of Boxe. 

The term "osteosarcoma n is commonly used to denote sarcoma 
of bones, but in reality it signifies simply a sarcoma which is ossi- 
fying or which contains bone, it being used in the same way as is 
fibrosarcoma. It is. therefore, a term which, in this connection, 
should be dropped. Sarcoma of bone may in general be divided 
into two kinds — according to its seat in the periosteum or in the 
medullary tissue of the bone. The former class is called "perios- 
teal sarcoma ; n the latter, " central" or "myeloid sarcoma." The 
latter division shows a marked difference in histological structure, 
for the periosteal growths are spindle-cell tumors and the medullary 
growths are mant-cell sarcomata. Round-cell sarcoma is seen also 
both in central and in peripheral growths. Some of these tumors 
belong to the most malignant class of all tumors, and others are 
so mildly malignant that they have been supposed to be benign. 
According to Gross's computations, the spindle-cell form is sup- 
posed to be 43.5 per cent, more malignant than the central giant- 
cell sarcoma. The giant-cell form is fortunately the commonest. 

Sarcomata of bone appear chiefly during the early half of life. 
Thus, they are seen most frequently between the ages of twenty 
and thirty, and they are almost as commonly met with between 
those of ten and twenty. Traumatism was found by Gross to be 
an assignable cause in fullv one-half the cases he collected. 



SARCOMA. 713 

According to Nasse, in no other form of tumor is the statement of 
the patient so often made that some sort of an injury had previously 
been received. Surgeons are yet, however, entirely in the dark as 
to the origin of these tumors. 

The myeloid tit mors are essentially a polymorphous cell-growth, 
the most striking of the various cell-forms being the giant-cells, 
which have been referred to above. Spindle-cells and round cells 
are also seen. They are usually situated in the centre of the bone, 
but are occasionally seen in peripheral growths. One of the most 
frequent points of origin is the spongy tissue at the head of the 
tibia. They are seen also in the upper and lower jaw and in all the 
other long bones. In these situations they appear as soft ma- 
hogany-colored growths, which are very characteristic. For a long 
time they are surrounded by a shell of cortical bone, but eventually 
they break through at some point. They are not so vascular as 
might be expected from their succulent nature and from the inter- 
stitial hemorrhages to which they are so liable. They are particu- 
larly liable to fatty degeneration, and thus have a soft creamy or 
an amber color. They also undergo a mucoid softening, as a re- 
sult of which cysts are formed containing a straw- or a buff-colored 
fluid. Owing to the fact that these tumors often pulsate, they are 
not infrequently mistaken for aneurism. They are found with 
about equal frequency in men and in women, and usually be- 
tween the ages of twenty and thirty years. They grow more 
slowly than any other form of sarcoma of bone, and, as a rule, 
are confined to the parts in which they originate and grow; but 
sometimes they recur after removal, and occasionally form me- 
tastatic deposits in distant organs, principally the lungs. In 22 
cases operated upon, Gross found that seventeen remained perma- 
nently well and five died of recurrence of the disease. 

Central spindle-cell sarcoma is the next commonest variety. 
The cells may be large or small, and it is found that the small 
cell type is much more malignant. This form of sarcoma occurs as 
a smooth or slightly nodulated growth, limited by a capsule which 
is partly bony and partly periosteal. The cut surface is usually of a 
grayish-white color, and the consistence is firm and elastic. The 
growth is not particularly vascular, and retrograde changes are 
uncommon. In 16 cases Gross found two in the upper epiphysis 
•of the tibia, five in the lower epiphysis of the femur, and two in the 
upper epiphysis of the humerus. The ages of the patients varied 
all the way from ten to sixty-eight years, the duration of life, from 
the beginning of the disease, averaging 37. 2 months. Metastatic 



7i4 



SURGICAL PATHOLOGY AND THERAPEUTICS. 



deposits are seen in many cases, particularly in the small-cell 
variety. Spontaneous fracture is met with in about one-half the 
cases. Pulsation is not felt frequently in this form of sarcoma. 
Central round-cell sarcoma is either a simple round-cell sarcoma 
or an alveolar sarcoma. The latter form, which is often exces- 
sively vascular, has been regarded by some writers as a plexiform 
angiosarcoma. These central round-cell sarcomata are generally 
globular or ovoid, and are of a smooth, even outline. They are 
contained in a capsule which is either membranous or osseous, and 
from the inner surface of the capsule bands are given off which 
give it a lobulated appearance. The simple round-cell sarcomata 
are not particularly vascular, but the alveolar form is often so rich 
in vessels that pulsation takes place. A pulsating central sarcoma 

of the shaft of a long bone is al- 
most always composed of round 
cells. Pulsation of the myeloid 
tumor at this point rarely occurs. 
Extensive hemorrhages may take 
place, and the seat of the disease 
may be converted into a large 
blood-cyst, the walls of which are 
ijl^vs composed of a thin layer of the 

S < v l*3Hk - original sarcomatous tissue. In 

A ,V such cases the so-called "sponta- 

neous fracture" not unfrequently 
occurs. These tumors also undergo 
fatty or myxomatous degeneration. 
They grow more rapidly than any 
other form of tumor of bone, some- 
times attaining a very large size. 

These growths not only infil- 
trate the medulla of the bone, but 
% 'fft£ , ^ r '' occasionally also invade the sur- 

rounding muscles and the liga- 
ments of the adjacent joints. En- 
largement of the neighboring 
lymphatic glands occurs occasion- 
ally. Gross found this enlarge- 
ment to exist in only three in- 
stances. Metastatic deposits were 
found by him in one-third of the cases, the lungs, pleura, liver, kid- 
neys, and osseous system being the various points invaded at differ- 







. 



Y 



■i 



'• -. ^ 



o 




Fig. 103. — Periosteal Sarcoma : amputation 
at the hip-joint (Warren Museum, 1 517). 



SARCOMA. 715 

ent times. In one case a large vein was found filled with the sar- 
comatous tissue. Of 12 cases of round-cell sarcoma observed by 
Gross, three ran their course without amputation. Of these cases 
one died in six months, one in twenty-seven months, and one in 
thirty-eight months. Of the 9 cases in which amputation was 
performed, five died of the operation, one died eleven months sub- 
sequently from secondary growths in the brain and skull, and three 
remained well, respectively, six weeks, four months, and four and 
a half years after amputation. 

Periosteal sarcomata are seated between the deeper layers of the 
periosteum and the bone (Fig. 103). The varieties are round-cell 
sarcoma, the spindle-cell sarcoma, osteoid or osteosarcoma, and 
chondrosarcoma. These forms of sarcoma occur more frequently 
in early life, the average age being estimated by Gross at twenty- 
two and one-seventh years. Giant-cells are occasionally seen in 
these tumors, but only to a limited degree. Fracture of the bone 
rarely occurs, and the tumors do not pulsate. Elevation of the 
local temperature is often marked. These tumors are not sur- 
rounded by a shell of bone as in the central sarcomata. 

The round-cell sarcomata are either of the simple round-cell 
type or they may belong to the class of alveolar sarcoma. They 
are found principally on the shafts of the long bones. They are 
more malignant than the central sarcomata, and their growth is 
usually continuous and rapid. As they grow by deposits on the 
periphery, the bone is usually at first not affected, although it may 
later become involved. They appear as more or less spindle- 
shaped swellings, and on the cut surface they have a radiating 
grain or are more or less lobulated. The skin is often involved in 
the growth when fully developed. These tumors may recur 
locally, and the lymphatic glands are more frequently affected 
than in the case of myeloid sarcoma. In many cases the lungs 
contain metastatic deposits. The average duration of life is esti- 
mated by Gross at eighteen months. Of 6 cases that were suc- 
cessfully operated upon, only one remained well without local 
recurrence. 

The spindle-cell sarcomata surround the epiphyses more fre- 
quently than they do the shafts of the long bones. They con- 
sequently assume more or less a pear shape. The spindle-cells 
vary greatly in size. While the outer layers may be rich in cells, 
the inner layers contain more or less fibrillated cartilaginous or 
bony intercellular substance. This growth, however, rarely in- 
volves the bone or the cartilage. The development of these 



yi6 SURGICAL PATHOLOGY AND THERAPEUTICS. 

tumors is, as a rule, uninterrupted and comparatively slow, but 
they appear to be almost invariably followed by metastatic deposits, 
and they recur frequently after operation. Their average duration 
of life is estimated by Gross at twenty months, or seventeen months 
less than the mean life of the central spindle-cell sarcomata. 

Osteoid sarcomata usually occur as long pear-shaped tumors, 
involving the epiphysis and a portion of the shaft of the bone. 
They are composed of bony or calcified tissue, and of a cell- 
growth which is usually of the spindle-cell variety, but many 
also contain round cells. The bony growth radiates from the 
bone in the form of bony plates or spiculae, which pursue a 
course perpendicular to the surface of the affected bone. The 
shaft is usually not involved in the disease, but at times the 
medullary canal may be occupied by a growth of dense bone, 
which may assume an ivory hardness. The outline of the shaft 
of the bone may still be seen on section running through the 
tumor. 

Osteoid sarcoma, or osteosarcoma, as it grows shows a tendency 
to extend beyond the limiting capsule and to invade the surround- 
ing structures. The lymphatic glands are infected in about one- 
fourth of the cases. Osteoid sarcomata are followed by metastatic 
growths in the internal organs, and are regarded by Gross as the 
most malignant of all forms of sarcoma of bone except the pure 
periosteal spindle-cell sarcoma, since 65.62 per cent, of all cases 
die sooner or later with metastatic deposits, whether they have 
been subjected to operation or not. 

Chondrosarcoma resembles closely the above variety in the 
earlier stages of its development, the nature of the cell-growth 
being the same in both cases. The newly-formed cartilage is 
found in the deepest portions of the tumor near the bone. The 
radiating character of the growth is also a well-marked peculiarity. 
Combination of the two forms not infrequently occurs, and on sec- 
tion some of these tumors (which frequently reach immense size) 
show patches of myxomatous and sarcomatous tissue, cartilage, 
and bone, and they present a most striking pathological and varie- 
gated appearance. 

Epulis (ini, upon, ouXov, the gum) is a name given to any growth 
upon the gums. The term is chiefly used, however, to denote a form 
of periosteal sarcoma. An epulis may contain round cells, but it is 
more frequently of the spindle-cell variety, and the growth is charac- 
terized by the presence of giant-cells, usually in large numbers. For 
this reason, and for the reason also that the bone is often involved, 



SARCOMA. 717 

some writers have undertaken to describe a central as well as a perios- 
teal form. It is, however, periosteal in its origin, but inasmuch as 
the growth may spring from the periosteum of the alveolar process, 
the bone may become affected by the time the growth has pushed 
aside the tooth and made its appearance. As the tumor grows the 
bone becomes softened and eroded, and the whole thickness of the 
alveolar process, and even the medullary portion of the bone, may be- 
come involved. Virchow distinguishes two forms, a hard and a soft 
epulis. In some cases there is a large amount of fibrous tissue and 
very few small cells, but the giant-cells are also seen here and there 
between the fibres. The softer kind is quite vascular, and fre- 
quently a vessel breaks and hemorrhage takes place into the tissue 
of the growth, pigment-granules being left behind when the clot 
is absorbed. These granules are found both in and between the 
cells, and they give the tumor a brownish color (pigmented epulis). 

This disease is one of early life, but it may appear also in mid- 
dle or in old age. It is usually seen, in the early stages, between 
two teeth, pushing forward as a bright red lump or granulation and 
attached apparently to the gum, often only by a pedicle. The 
deeper tissues are involved, however, and the lump returns promptly 
after an attempt to destroy it by tying a ligature around its base, as 
is often done. The disease is only locally malignant, and it may 
return several times after operation when not enough of the sur- 
rounding tissue has been removed. It is necessary to extract the 
adjacent teeth and to remove that portion of the alveolar process to 
which the tumor is attached. In rare cases, when the tumor is 
small, an incision down to the periosteum around its base will 
enable the surgeon to peel off the periosteum with the growth, and 
in this way effect a cure. Sometimes a large portion of the bone of 
the lower or the upper jaw must be removed to prevent recurrence. 

Sarcoma of the bones of the cranium occurs as a periosteal or as 
a myeloid sarcoma. The periosteal form grows outward princi- 
pally, but it may grow inward and destroy the bone and invade 
the cranial cavity. The myeloid form destroys first the diploe and 
separates the two tables from each other, but for some time the 
growth remains covered by a bony capsule. Externally these 
tumors may become quite prominent, and eventually they break 
through the cutaneous coverings. Internally they push the dura 
before them, but they do not become so prominent in this direc- 
tion. Occasionally other portions of the bone are attacked and 
multiple tumors are formed. The periosteal tumors are either 
spindle-cell or small round-cell sarcomata. 



7i8 SURGICAL PATHOLOGY AND THERAPEUTICS. 

The most frequent seat of these tumors is in the parietal bone, 
the temporal and frontal bones coming next in order. Tumors 
springing from the dura mater grow principally into the cranial 
cavity and compress the brain. If the tumor grows from the outer 
layers of the dura, the bone is first absorbed, and through the hole 
thus made the tumor grows out, sometimes reaching a formidable 
size. The tumor is usually covered with a connective-tissue cap- 
sule, which consists of the outer layer of the dura that separates it 
from the cranial bone. Sometimes the growth behaves more like 
an ordinary periosteal sarcoma, and it becomes intimately connected 
with the bone from the beginning. Sarcoma of the dura is usually 
a spindle-cell sarcoma. Its most frequent seat is beneath the parietal 
bone. It attacks principally individuals of middle or of late life. 

J. C. Warren describes a "fungoid tumor" growing from the dura and 
forming a large growth on the right temple of a young lady who applied for 
treatment in 1846. The tumor was cut away close to the bone, and the dura 
was cauterized and the wound healed. Five years later she consulted Mason 
Warren for a return of the growth, which was quite small. Xo operation 
was advised. In 1S66 she was heard from in good health. The tumor had 
slowly enlarged until three years previously, and it since had undergone no 
material change. 

Other cases of slow growth of these tumors are recorded : one 
of twenty years' , one of fifteen years' , and several of four or five 
years' duration. 

3. Sarcoma of Kidxev. 

Primary sarcoma of the kidney is not common, and it is most 
frequently seen in infancy or in childhood, whereas cancer of the 
kidney at this period of life is extremely rare. Many of these 
growths are congenital, and are discovered at or soon after birth. 
Sarcoma of the kidney is generally a very soft medullary growth 
composed of round or spindle-cells and also of stellate cells. In 
some portions of the tumor may be found fibrous or myxomatous 
tissue. The tumors attain at times considerable size, which may 
exceed that of a man's head. These large tumors are filled with 
fatty degenerated necrotic or hemorrhagic portions and cysts. 

True cysts with an epithelial lining are rare. Remains of the 
kidney structure may be found in the peripheral portion of the 
tumor. The capsule is generally preserved, as are also the adrenal 
glands. The renal tubules and pelvis may generally also be found. 
The sarcoma appears to develop in the inner portion of the organ. 
The renal vein, and even the vena cava, may be invaded by a mass 



SARCOMA. 719 

of sarcomatous tissue. The lymphatic glands are eventually affected, 
and secondary deposits may be found in the other viscera. In a 
large number of sarcomata of the kidney both striped and unstriped 
muscular fibre are found (myxosarcoma). The presence of such 
structures in the tumors is regarded by many pathologists as evi- 
dence of a disturbed embryonic formation, but Orth thinks that it 
is possible that these muscular growths -may develop from the 
muscular fibre of the urinary tract. Such tumors are usually per- 
fectly encapsuled, are separable without much difficulty from the 
surrounding tissues, and are not associated with involvement of the 
lymphatic glands or with secondary growths in any other part of 
the body. The disease is limited to one kidney. 

Angiosarcoma may be found in the kidney, although it is an 
extremely rare growth. The kidneys maybe the seat of metastatic 
sarcoma, and also of lymphosarcoma, nodules of which are seen 
also in the lymphatic glands. Gross collected in 1885 the statistics 
of 33 cases of nephrectomy for sarcoma of the kidney. The mor- 
tality of the operation was 57. 57 per cent. Of the fourteen survivors, 
five were known to have died of metastases at periods varying from 
five to eighteen months; five were alive and well at the end, re- 
spectively, of seventeen, twenty-two, twenty-three, and thirty-five 
months, and five years. Of the 33 cases, sixteen were children 
under seven years of age ; of these, seven survived the operation. 
Of these seven, one was living at the end of four mouths, and the 
others died of recurrence in five, six, nine, and eighteen months, 
respectively. In one of the cases that died secondary deposits were 
found in other organs. An analysis of the adult cases shows that 
seven of the seventeen recovered, and five were well at the end of 
thirty-one and a half months, on an average. From these data 
Gross concludes that nephrectomy for sarcoma in children should 
not be performed, but that in adults it is eminently justifiable, as it 
apparently cures 29.41 per cent, of the cases. 

4. Sarcoma of Bladder. 

Sarcoma of the bladder is an extremely rare affection. The dis- 
ease is seen more often in childhood or in youth than at other 
periods of life. Hinterstoiser in a collection of 20 cases of sarcoma 
of the bladder found five in persons under twenty years of age. 
There were six cases, however, between the ages of fifty and sixty. 
The disease occurs more frequently in males than in females, thir- 
teen of these cases being males. Some of the tumors are round- 
cell sarcomata, and they bear a close resemblance to the lympho- 



720 SURGICAL PATHOLOGY AND THERAPEUTICS. 

sarcomata; some have spindle-cells, and in some there is a mixture 
of the two kinds of cells. Myxosarcomata are occasionally seen, in 
such cases unstriped muscular cells being found mingled with the 
sarcoma-cells. Chondrosarcoma is seen in connection with polypoid 
growths (Orth). In a collection of 20 cases of tumor of the bladder 
by Sir Henry Thompson the writer finds one stated by him to be 
probably sarcoma, one which was probably myxosarcoma, and one 
which was probably round-cell sarcoma. Winckel reports a remark- 
able case of round- and spindle-cell sarcoma of the bladder in a girl 
three years of age. The tumor sprang from the anterior wall of the 
bladder, by the contraction of which it was forced into the urethra, 
whence it pushed its way into the vagina, distended this, and even 
dilated the os uteri. 

In 88 cases of tumor of the bladder collected by Albarran, sixty- 
eight were carcinoma, three were sarcoma, and seventeen were 
benign tumors. Secondary sarcoma is occasionally found in the 
bladder. Fenwick in an examination of 600 cases of tumor of the 
bladder found but five that were really secondary (direct extension 
of a tumor into the bladder not being included), and of these four 
were sarcoma. Cabot reports a case of tumor of the prostate and 
bladder seen secondary to sarcoma of the testis. 

5. Sarcoma of Uterus. 

Sarcoma of the uterus springs from the mucous membrane or 
from the body of the uterus. In the latter case sarcoma-growths 
seem to be developed from a previously existing fibromyoma. In 
both forms round cells are found, but in the sarcoma of the body 
of the uterus may also be seen spindle-cells. Many observers have 
reported the presence of giant-cells. 

Sarcoma of the mucous membrane appears earlier in life than 
carcinoma, sometimes even before puberty, and comparatively 
often in women who have not borne children. It is situated gen- 
erally in the body of the uterus and rarely in the cervix. Lobu- 
lated or polypoid growths are usually developed, and the surface 
may become ulcerated. In both cases there is considerable hyper- 
trophy of the uterus-wall, which becomes infiltrated by the new 
growth. When the wall has been perforated the disease attacks 
the peritoneum and the intestines through the adhesions which 
have been made, and it even attacks the abdominal walls. Poly- 
poid papillary or cauliflower growths which are distinctly sarcoma- 
tous may occur in the cervical canal or at the os. Combinations 
of leiomyoma and rhabdomyoma, or tumors containing unstriped 



SARCOMA. 7 21 

or striped muscular fibre, may be observed in these growths, and Orth 
reports a case in which both forms of muscular fibre were observed. 

The mural sarcomata or fibrosarcomata are found in the wall of 
the nterns, and chiefly in the body rather than in the cervix. They 
are combined with muscular cells, the sarcomatous cells usually 
being situated at the centre of the growth, as if a fibromyoma had 
undero-one a sarcomatous change. These tumors resemble more or 
less, in their coarse appearance, the uterine fibroids, and they are 
often found in the interior of the uterus as a polypoid tumor (Orth). 

In some cases these sarcomata appear not as isolated growths, 
but as infiltrations of the uterine wall. They are chiefly composed 
of round cells, and they are often soft and medullary. Some of 
the uterine sarcomata may attain immense size. Gusserow reports 
the case of a woman fifty-one years of age with a sarcoma the size 
of a child's head, which tumor, on being expelled from the uterine 
cavity, proved to be a round-cell sarcoma. Some of the sarcomata 
are exceedingly vascular, and they resemble angiosarcoma. Others 
closely resemble carcinoma, but they are probably endothelioma. 

Metastatic deposits are not often found, and less frequently in 
the diffuse forms. The retroperitoneal glands may be affected, and 
metastases may be found in the lungs, the liver, the pleura, and 
the adjacent organs, and the bladder and vagina may be affected 
by direct extension of the disease. 

As the disease progresses cachexia becomes very marked, and 
death usually occurs from peritonitis, pyaemia, or intestinal ob- 
struction. The progress of the disease is slow, many cases having 
been observed in which the disease existed ten years before death. 
Operative interference rarely effects a cure. A few doubtful cases 
have been reported as permanently cured. The growth, however, 
usually returns after operation. In 50 cases reported by Rogivue, 
three appear to have been cured; in thirty-two return of the disease 
was known to have taken place; and in all but two cases this return 
occurred within a year after the operation. 

6. Sarcoma of Testis. 

Sarcoma of the testis is much commoner than carcinoma. It 
occurs during both childhood and middle life, and even in old age. 
It has been seen in a child five months old and in a patient 
seventy years old. It is occasionally observed to follow a blow, 
but more frequently it occurs without any known cause. It is an 
interesting fact from an etiological point of view that it is not 
infrequently seen in both testicles. Langhans has collected 15 

46 



722 SURGICAL PATHOLOGY AND THERAPEUTICS. 

such cases, in many of which the second testicle has been affected 
several months after the removal of that first diseased. Sarcoma 
may occur also in the testicles as a secondary disease. 

Histologically considered, there are two forms of sarcoma of 
the testicle — the spindle-cell and the round-cell sarcoma. In the 
spindle-cell variety the cut surface shows a firm growth of 
homogeneous appearance, with a few cysts in the substance of the 
tumor. The spindle-cells are found lying between the seminal 
ducts, which are often quite well preserved. The round-cell 
sarcoma mav be a large- or a small-cell growth, and it mav even 
contain giant-cells. Alveolar sarcoma is not infrequently seen. 
Many of the small-cell sarcomata probably belong to the lympho- 
sarcomata. It is this variety which is most liable to attack both 
testicles and which is most malignant. Cartilage, myxomatous 
tissue, and unstriped muscular cells are sometimes found in 
sarcoma of the testis. The round-cell variety is seen more often 
in children. Occasionally the disease assumes the form of an 
angiosarcoma or a plexiform sarcoma. 

The disease appears to take its origin, in the majority of cases, 
in the posterior portion of the testicle or in the epididymis and 
cord. Kocher observed three cases in which the disease began in 
the epididymis. If the testis is first involved, the growth enlarges 
as a nodular tumor inside the organ, which it gradually destroys. 
When the growth has attained considerable size the tissue of the 
testis is often seen spread out over the tumor in a thin layer. The 
epididymis retains for some time a well-defined outline on the 
posterior wall of the tumor. Finally the tunica albuginea be- 
comes involved and is merged in the sarcomatous growth, and 
the tunica vaginalis may follow in the same way. A hydrocele, 
or even a haematocele, may occasionally develop during the course 
of the disease. Nodular enlargement of the cord is often observed 
as the disease progresses. 

The disease begins as a painless enlargement of the testicle, 
which may exist for many years before a rapid growth takes place. 
It is quite difficult to make a diagnosis between sarcoma and 
carcinoma, and usually the microscope alone will settle the 
question. The lymphatic glands are frequently affected, and in 
well-developed cases a large abdominal tumor may be found, 
caused by the involvement of the retroperitoneal glands. Meta- 
static deposits may occur in the skin, in the lungs, in the liver, 
and in the brain, and occasionally in the abdominal organs. 

Sarcoma of the testicles usually runs a rapid course in children, 



SARCOMA. 723 

but in adults the disease may last from eight or nine months to 
one or two years. In the great majority of the cases, according to 
Kocher, the disease returns after operation, either locally or in 
distant organs. One or two cases of undoubted permanent cures 
are reported in children, and numerous cases of immunity for 
several years are reported in adults. 

7. Sarcoma of Breast. 

Sarcoma of the breast includes nearly all the various forms of 
sarcoma. Round-cell sarcoma appears usually as a medullary 
growth, and Billroth describes such a form in a girl nineteen years 
of age. In this case there were striated spindle-cells, showing the 
development of striped muscular fibre in the tumor. In a case of 
round-cell sarcoma of the breast which the writer examined 
microscopically the growth appeared to develop around the walls 
of the blood-vessels. 

Cases of lymphosarcoma are occasionally mentioned, and also 
alveolar sarcoma. The great resemblance of the alveolar type of 
sarcoma to carcinoma has doubtless caused it to be mistaken fre- 
quently for the latter disease. Billroth reports a case of alveolar sar- 
coma which assumed a melanotic type. In this case pigment-moles 
existed on the face and back before the development of the tumor, 
and metastatic deposits formed soon after the removal of the 
breast. Giant-cell sarcoma is found also in the breast, usually as 
an alveolar sarcoma. It is, however, a rare form of the disease. 
Spindle-cell sarcoma is seen in the variety known as cystosarcoma. 
This is the commonest form of sarcoma of the breast. As a rule, 
these growths, with the exception of the cystosarcoma, are 
unattached to the gland, but they push it aside and compress it. 

While the round-cell sarcomata are soft and medullary, the 
spindle-cell sarcomata are firm, and in places fibrous, and are 
dotted over with the numerous little cysts caused by a distortion 
of the glandular tissue of the breast. Some of these cystic tumors 
contain portions that are myxomatous, and cretaceous material and 
some bone have been found in them. The cystosarcomata often 
grow to enormous size. In many cases the skin over the tumor in 
the different forms of sarcoma becomes involved and a hernial pro- 
trusion of the growth takes place. 

The commonest seat of the disease is beneath the nipple, but when 
it develops at the circumference of the organ it is usually in the upper 
and inner quadrant. The central growths are usually cystic. 

Sarcoma differs markedly from carcinoma in that it is found in 



724 SURGICAL PATHOLOGY AND THERAPEUTICS. 

early life. In 60 cases collected by Gross, eight appeared between 
the ages of ten and twenty years ; ten appeared between twenty and 
thirty years ; twenty-three appeared between thirty and forty years; 
and thirteen appeared between forty and fifty years. Spindle-cell sar- 
coma develops earlier in life than round-cell sarcoma. The giant-cell 
sarcoma alluded to above appeared in the forty-second year. The 
rate at which these tumors grow varies greatly. The small-cell 
tumors develop as a rule more rapidly than spindle- or giant-cell 
growths. 

During its progress the tumor remains mobile and free from 
attachments. If the skin is not perforated, it remains natural in 
color. When the tumor attains considerable size, which is the case 
in cystosarcoma, the subcutaneous veins may be enlarged, and may 
give to the growth a much more malignant appearance than it 
really has. The nipple is usually not retracted. The lymphatic 
glands are rarely affected, and the contrast in this respect between 
sarcoma and carcinoma is very striking. 

In regard to the prognosis of sarcoma of the breast, Gross, with 
his accustomed enterprise, collected 156 cases of the disease, the 
data of which throw much valuable light upon this point. The 
reputation of sarcoma in this situation had been that of a compara- 
tively benign tumor. The growth was supposed to show a decided 
tendency to recur after operation, but the generalization of such 
growths was supposed to be comparatively rare. The local infec- 
tion of structures adjacent to the mammary gland is indeed exceed- 
ingly rare, but Gross found metastasis to be much commoner than 
was supposed to be the case. The prognosis appears to be influ- 
enced materially by the age of the patient and by the size and the 
rate of increase of the tumor. Before the age of thirty-five, when the 
mammary gland is functionally most active, a small, slowly-growing 
sarcoma does not return; but a rapidly-increasing tumor, especially 
the cystic variety, is thought by Gross to be very liable to recur. 
After this period the danger of metastasis increases with advancing 
age. "A sarcoma occurring in a functionally active breast evinces 
a marked disposition to recur after operation, with less disposition 
to metastasis, while a sarcoma of the declining breast recurs less 
frequently, but is generalized in a greater number of instances. ' ' 

The round-cell sarcoma is said to be the most malignant, but 
the cystosarcoma recurs, according to Gross, in more than one-half 
of all the cases. The good reputation of this growth maintained 
by numerous writers is doubtless due to the close resemblance of 
sarcoma to fibroma of the cystic type. Notwithstanding frequent 



SARCOMA. 725 

recurrence, the removal of the tumors as fast as they appear seems 
to prolong life. Erichsen in 1859 removed the breast for a cysto- 
sarcoma, and operated five times for the recurrent growth between 
that date and 1866, the patient dying, some years after the last 
operation, of another disease. S. D. Gross in 1857 enucleated from 
the left breast a small tumor which proved to be a spindle-cell sar- 
coma. Between that date and 1862 the patient underwent twenty- 
one operations. Ten years and nine months after the last opera- 
tion she was in perfect health. 

According to Gross, sarcoma has a greater tendency to metastasis, 
than has carcinoma ; but this statement the writer hardly believes 
to be correct, for it is based upon the supposition that in carcinoma, 
metastases are found post-mortem in only fifty per cent, of the cases. 
Gross estimates the average life of round-cell sarcoma at fifty-four 
months, of spindle-cell sarcoma at ninety months, and of giant- 
cell sarcoma at one hundred and eight months. It appears from 
an analysis of the data offered by Gross that, although sarcoma 
of the breast has a decidedly malignant tendency, surgical inter- 
vention prolongs life, and it probably results in permanent recov- 
ery. The patient may be considered safe from recurrence of the 
disease if four years have elapsed since the last operation. 

8. Sarcoma of the Air-passages. 

Sarcoma of the tonsil is a much more common disease than has 
usually been supposed. In Boston alone quite a number of 
operations have been performed for this affection, that of Cheever 
by the external method being the first recorded operation of its 
kind. Cases have also been reported by Homans and Richardson. 
An unrecorded case was operated upon successfully by Porter. The 
writer also had one case, not reported, the patient dying about one 
week after the operation. Newman mentions ten cases observed 
by himself, and he succeeded in collecting (1892) 52 cases of sar- 
coma of the tonsil. Of these, nine were stated to be round-cell 
sarcoma and eighteen were called "lymphosarcoma." A case 
examined microscopically by Gray proved to be alveolar sarcoma. 
The disease is stated by Butlin to attack males principally, and 
between the ages of twenty and sixty years. As several cases of 
disease of both tonsils are reported, it is probable that a certain 
percentage of the cases belong to the family of lymphosarcoma. 
Cases of spindle-cell sarcoma have been reported. 

The slight enlargement of one of the tonsils usually causes 
the patient to present himself for treatment. There is nothing 



726 SURGICAL PATHOLOGY AND THERAPEUTICS. 

in the local appearance at this time to suggest the presence 
of malignant disease if the description of reported cases may 
be trusted. Presently the tonsil begins to grow rapidly : it pro- 
jects toward the median line, and at the same time the anterior 
pillar of the fauces and the soft palate become reddened and 
infiltrated. By this time it will be found that there are other 
nodules than that of the original tumor. Growths may be ob- 
served below in the pharynx, and others may be felt externally in 
the cervical region. Glandular infection appears to occur early, 
and it is sometimes quite extensive. In the case upon which 
the writer operated a row of retropharyngeal glands on the affected 
side were exposed and removed. 

As the disease progresses swallowing and articulation become 
difficult, and occasional attacks of dyspnoea are observed. Meta- 
static deposits have been observed in the lungs, the liver, the mes- 
enteric glands, the intestine, and the peritoneum. Death, how- 
ever, probably takes place in most cases before the disease has 
become generalized, owing to the exhaustion of the patient's 
strength by local complications. These growths have been re- 
moved through the mouth by knife, by ecraseur, or by galvano- 
cautery, and through the neck by external incision. 

The prognosis of the early operations seems to have been most 
unsatisfactory, due probably to the fact that the nature of the 
malady had not been recognized sufficiently early to enable the 
surgeon to obtain a satisfactory result. Butlin mentions two cases 
in which there had been no return at the end of one and two years, 
respectively. Cheever says : "So far as I know, recurrence has 
taken place in all my cases in from four to six months. It has 
occurred usually in the glands of the neck — once on the palate. 
I believe I have now operated four times, always with temporary 
relief and good recoveries from the operation." Homans' case 
was reported well eighteen months after operation, and Richard- 
son's case was in perfect health five years after the operation. 
Suffocation may be produced, not only by the growth of the tumor, 
but also by hemorrhage, which is a common accompaniment of 
malignant disease of the tonsils. 

Sarcoma of the larynx is a comparatively rare disease. It is 
not often seen in childhood, but it is an affection of middle and 
advanced life. In 13 cases collected by Wasserman, two occurred 
between ten and nineteen years of age, two between twenty and 
thirty, and eight between forty and sixty. Most of the cases are 
found in males, at least three times as many males as females being 



SARCOMA. 727 

attacked. Nearly all the varieties of sarcoma are said to be found 
here. Butlin mentions the spindle-cell sarcoma as the principal 
form, but round-cell, giant-cell, and alveolar sarcomata have been 
observed. 

Sarcoma of the larynx generally originates in the subcutaneous 
tissue, grows slowly, and does not attain a very large size. It 
most frequently originates in the interior of the larynx, and princi- 
pally upon the vocal cord or on the ventricular band, as irregular 
spheroidal masses, smooth, nodulated, mammillated, or even some- 
what dendritic. Thence the growth may extend outward by infil- 
tration, penetrating not only the membranous, but even the car- 
tilaginous, framework of the larynx (Cohen). It is sometimes 
deeply ulcerated, like cancer, and at other times it is covered with 
a normal or congested mucous membrane. The epiglottis may 
also be the seat of sarcoma. 

The glands are usually unaffected, and in this respect the prog- 
nosis of the disease is more favorable than that of carcinoma. 
There does not appear to be any tendency to metastasis. Death 
usually takes place from obstruction of the air-passage before the 
growth reaches a sufficient size to lead to generalization of the 
disease. 

A number of operations for excision of the larynx for sarcoma 
have been performed in which the patients have been reported well 
one and two years after the operation, and one case has been 
reported as well ten years after the operation. 

Sarcoma of the nasal passage is not a very rare disease. Bos- 
worth collected forty-one cases. The round-cell and alveolar forms of 
sarcoma seem to be the prevailing types of growth. Fibrosarcoma 
and myxosarcoma are seen, and also angiosarcoma and melanosar- 
coma. The disease occurs as a pediculated tumor attached, with 
about equal frequency, to the outer and the inner wall of the nasal 
cavity. The average age at which the disease appears is about forty 
years, and it is seen about equally in males and in females. The 
disease does not appear to show the same malignant tendencies in 
the nasal passage that it does in other localities. Many of the 
reported cases were well without recurrence several months after 
the operation. The single case seen by the writer was that of an 
old woman from whom he removed a sarcomatous polyp with the 
cold wire-snare. The tumor was so large that it could not be 
extracted without turning back the left ala nasi. She made a good 
recovery, and was then lost sight of. 

Nasopharyngeal polypi are often sarcomatous, although they 



728 SURGICAL PATHOLOGY AND THERAPEUTICS. 

may be examples of almost pure fibroma. These growths occur 
most frequently in males at about the age of puberty. They grow 
from the base of the skull, often originating in the retromaxillary 
fossa, whence they send out prolongations into the nose, the 
pharynx, and beneath the zygoma. The sarcomatous variety of 
this tumor may be a spindle-cell sarcoma or a myxosarcoma. At 
times it is highly vascular, and cases of death from hemorrhage 
have not infrequently occurred during attempts at removal. A 
very curious feature of this growth is that it shows a marked 
tendency to disappear at the period when the skeleton becomes 
fully ossified, although it frequently recurs before that period after 
operation. According to Bosworth, the disease may occur also 
later in life. 

The writer has operated on several cases of sarcoma in this region in young 
men. In the first case the disease was limited to the nasopharynx and the 
tumor projected from the nostril. Frequent hemorrhages had much reduced 
the patient. The growth was removed with the galvano-cautery loop, and it 
proved to be a myxosarcoma. For two or three years after the operation 
fragments of tumor were removed by Dr. Hooper from the pharynx. Finally, 
one day, when the patient had been sent for to consider the question of an 
osteoplastic resection of the jaw, it was found that the growth had disap- 
peared. The writer saw the patient several years later and found him in per- 
fect health. A second patient applied with a similar growth which had sur- 
rounded the upper jaw and had appeared beneath the zygoma. The writer 
accordingly performed Langenbeck's osteoplastic resection of the jaw. Send- 
ing for him two or three years later, the writer found that in the mean time 
he had had two other operations performed — one through the jaw and one 
through the soft palate ; a recurrence had taken place after the last opera- 
tion, but the growth was then diminishing in size. The patient regarded 
himself as well. A third case was operated upon recently by the osteo- 
plastic method. 

Sarcoma occurs occasionally in the soft palate as a round-, 
alveolar-, spindle-cell sarcoma or myxosarcoma. Melanotic sar- 
coma has also been seen here. It usually begins on the side and 
extends across the palate. The neighboring tissues are rarely 
invaded. It occurs either early or late in life. It seems to have a 
tendency to remain encapsulated in many instances, and opera- 
tions for its removal have been successful. In 17 cases operated 
upon death occurred in seven; in eight cases a cure was obtained 
(Bosworth). 

Sarcoma is found also in the pharynx, where it is said to 
develop during middle life. Histologically, the disease does not 
differ essentially from the diseases above mentioned. It occurs 



SAfiCOMA, 729 

most frequently in a pediculated form, and the prognosis after 
operation is quite favorable. 

9. Sarcoma of the Digestive Tract. 

Sarcoma of the stomach is a rare occurrence. Torok mentions 
a case in which he performed resection. The patient was a female 
twenty-one years old. The tumor was quite firm and of the size 
of a fist. It proved to be a lymphosarcoma. A case of cystic 
sarcoma is mentioned among the cases for which a resection of the 
pylorus was performed by Billroth. Brodinsky reports a case of 
myosarcoma growing from the greater curvature of the stomach. 
The tumor weighed twelve pounds, and it lay between the layers 
of the omentum. Cavities were found in it varying in size from a 
walnut to a child's head. An ulcer the size of a hand was seen in 
the interior of the stomach at the point at which the tumor took 
its origin. The muscular layer of the stomach was much thick- 
ened, and a large portion of the tumor was made up of a growth 
of unstriped muscular fibre-cells. There were also spindle-cells. 
Nodules of the same character were found in the liver. This and 
a case of Eberth's of myosarcoma of the kidney were at the time 
the only reported cases of secondary myomatous growths. In 
Eberth's case the metastasis was in the diaphragm. 

Sarcoma of the intestine is exceedingly rare. Baltzer collected 
fourteen cases of undoubted primary sarcoma of the intestine. 
They were nearly all males (92.8 per cent.), and the disease oc- 
curred chiefly between the ages of forty and fifty years. In the 
majority of cases the growth was reported to be a small round-cell 
sarcoma. The disease appeared to develop from the mucosa or the 
submucosa. It seems to be a peculiarity of these growths that they 
do not cause intestinal obstruction. In 4 cases resection of the 
intestine was attempted, with death in two cases. The result of 
the operation in the other two cases was not reported. Spindle- 
cell sarcoma is reported by Leichtenstern and also by Edwards. 

10. Sarcoma of Brain. 

Sarcoma of the brain may occur as a primary or as a secondary 
growth. Primary sarcoma of the brain appears either as a hard or 
as a soft tumor, and it is usually flat or wedge-shaped. The 
former variety was originally called by Virchow u fibrosarcoma, ' ' 
and many of the denser forms of tumors are genuine fibromata. 
In many cases the cells abound, particularly spindle-cells, and in 
some of them the intercellular substance has an almost cartilagi- 



730 SURGICAL PATHOLOGY AND THERAPEUTICS. 

nous hardness. These types are firm, translucent, and of a gray- 
ish or a yellowish-white color (Knapp). 

The softer form may be a spindle-cell sarcoma purely or a 
myxosarcoma or gliosarcoma or a small round-cell sarcoma. The 
latter is the most malignant of the sarcomata in this region, 
except the melanotic form. It shows in sections a moist milky- 
white surface. Stellate and giant-cells are occasionally found in 
these growths, and many sarcomata are distinctly polymorphous in 
their cell-structure. Some forms are highly vascular and present 
appearances known as angiosarcoma. Sarcoma is sometimes 
easily separable from the surrounding cerebral tissue; in other 
cases it seems so continuous with the cerebral substance that it 
appears as a simple enlargement of the same. 

Sarcoma of the brain shows a tendency to undergo fatty 
degeneration which may produce an appearance strongly suggest- 
ive of a gumma. It appears to develop from the pial sheaths of 
the vessels, and it is known to occur at all periods of life. Meta- 
static deposits from primary sarcoma of the brain are not reported, 
but occasionally multiple growths occur within the brain that 
appear to have originated from a single nodule. Sarcoma of the 
pia mater may occur in that membrane as a diffused growth of 
endothelial origin, which growth may spread itself over a large 
surface, causing a thickening of the membrane which extends 
inward along the pial sheaths of the vessels of the brain and the 
cord. Ordinary types of sarcoma and myxosarcoma may, how- 
ever, develop from the pia mater. 

10. Lymphosarcoma. 

Lymphosarcoma is a disease to which various names have been 
applied, as is usually the case in affections whose true nature is 
obscure and in those which are confounded with other allied affec- 
tions. It is known also as malignant lymphoma, psendo-lenkczmia, 
and Hodgkirt s disease. It may be defined as a disease character- 
ized by an enlargement of the lymphatic glands and by the forma- 
tion of lymphatic tissue in the spleen, the liver, the kidneys, the 
intestine, and the lungs — more rarely in other organs as a diffused 
infiltration of the tissues of the body — and by marked anaemia and 
the absence of leucocythsemia. Owing to its name, as well as to 
the impossibility of classifying it with any other group of tumors, 
it seems best to place it in the same chapter with sarcoma. 

It has been customary to recognize among tumors of the lym- 
phatic glands the enlargements due to tuberculosis, syphilis, and 



SARCOMA. 



731 



other infectious diseases; the enlargements due to leucocythsemia 
in which is a greatly increased number of white corpuscles in the 
blood; the multiple tumors of lymphosarcoma; and, finally, simple 
hypertrophy of the lymphatic glands due to some of the above 
causes to which the term lymphoma has been applied. This term, 
originally used when the knowledge of the etiology and classifica- 
tion of these various affections was much more imperfect than it is 
at present, must now be dropped if it is intended to apply it in 
any other sense than as an enlargement of a lymphatic gland, no 
matter what the cause, as those cases which were supposed to 
occupy an independent position under the name of lymphoma or 
lymphadenoma can now be classified under some one of the other 
headings. 

The lymphatic tumors which are so prominent a feature of 
lymphosarcoma are composed of the tissue of the lymphatic 
glands. The lymphoid cells are found supported in a delicate 
reticulum. According as one or the other of these structures 
predominates, there will be a difference in the consistency of the 
tumors : a hard and a soft variety have been distinguished. 

The soft lymphatic tumors are almost fluctuating, and they con- 
tain a considerable amount 
of fluid, which flows when 
the tumor is cut open. The 
cut surface shows a grayish- 
white substance equally 
distributed over the growth, 
so that there is no distinc- 
tion between cortical and 
medullary portions. The 
lymph-cells are enormously 
increased in number (Fig. 
104). The harder tumors 
have a yellowish color and 
they are dryer and tougher. 
The capsule is much thick- 
ened, and there are numer- 
ous fibrous bands running 
through the tumor. These 
growths very rarely spread 
beyond their capsules, and they do not undergo cheesy degenera- 
tion. Suppuration is known to occur, but it is extremely rare. 

The disease usually begins in the cervical glands, which often 




Fig. 104. 



■Retroperitoneal Lymphosarcoma, show- 
ing cells and stroma. 



73* 



SURGICAL PATHOLOGY AND THERAPEUTICS. 



become enormously enlarged. One side of the neck is chiefly 
affected, and a large number of glands grow and form a swelling 
filling out the side of the neck and causing a great deformity (Fig. 
105). The glands do not run together into a single mass, but they 
are movable upon one another, and can be shelled out separately. 
The writer removed in this way as many as forty glands from the 




Fig. 105. — Lymphosarcoma (Warren Museum, Sp. 4635). 

neck of a boy. The axillary, inguinal, retroperitoneal, bronchial, 
mediastinal, and mesenteric glands become enlarged, usually in the 
above order (Gowers). The spleen is enlarged in the majority of 
cases, and in some instances it is almost the only gland affected. 
The tonsils, the thymus gland, the papillae of the tongue, and the 
follicles of the intestinal mucous membrane are also affected. In 
cases described by Flexner there were very few glandular tumors, 
but the structure of the mucous membrane of the intestinal canal 
had largely been destroyed and replaced by lymphoid tissue. In 
one of the reported cases the mucous membrane of the duodenum 
was of a dead-white color: it was infiltrated uniformly with an 



SARCOMA. 733 

opaque white material, and was marked here and there with small 
erosions and superficial ulcerations. 

Sessile and polypoid tumors are sometimes found in the 
stomach, and a portion of the wall of this organ may be trans- 
formed into a continuous infiltrated mass of the disease. Occa- 
sionally the medullary tissue of bones may undergo a lymphoid 
change, and may become like the red marrow of children, but this 
is not always the case. 

Metastases occur often in the liver and the kidneys, and also in 
the lungs, in which latter location they have been mistaken for 
tubercle. Large growths have been reported occasionally in the 
mediastinum. The trachea, pleura, peritoneum, heart, testicle, 
and ovary are also seats of the disease. In fact, there is hardly a 
spot in the body which may not be involved in the diseased pro- 
cess. The place of its origin, however, seems to be the lymphatic 
apparatus. 

The principal symptoms in the early stages of the disease are 
those caused by the glandular enlargements, which are chiefly in 
the cervical region. Usually there is no febrile disturbance, 
but occasionally recurrent elevations of temperature have been 
reported. The blood shows diminution in the number of red cor- 
puscles, without any increase in the number of white corpuscles, 
and toward the end of the disease there is marked anaemia com- 
bined with cedema and a tendency to hemorrhages. If the patient 
does not succumb to complications in the respiratory apparatus 
from pressure, death occurs from marasmus. The course of the 
disease is usually chronic, and it may sometimes last for years. 
Rarely the symptoms may be of the most acute type. Flexner 
reports the case of a girl eleven years of age who up to the day of 
her death had shown no symptoms of the disease. Death in this 
case was caused by cerebral hemorrhage. The lymphoid infiltra- 
tions were marked, but few glandular tumors were found. 

The disease appears slightly more often in men than in women. 
In ioo reported cases seventy-five were males and twenty-five were 
females. It occurs at all ages of life, although more frequently in the 
early half of life. Occasionally the colon bacillus and pyogenic cocci 
have been found in some of the enlarged glands, but the presence 
of these organisms is not constant, and it seems to have been acci- 
dental. They may account for those exacerbations of temperature 
which are found in certain cases. 

Flexner' s studies lead him to believe that in this disease there 
is a toxic substance capable of producing profound degenerative 



734 SURGICAL PATHOLOGY AND THERAPEUTICS. 

changes in certain tissue-elements of the body. He observed cer- 
tain bodies in the lymphoid tissue that possibly may belong to the 
kingdom of the protozoa. They are certainly foreign to the tissues 
in which they are found, and are not to be regarded as altered cells 
or as nuclei in the usual sense. They are round, oval, or slightly 
irregular in shape, and consist of a rim of protoplasm which stains 
faintly in eosine, and each cell contains a particle that stains in 
hsematoxylin. The stained particles in the interior of the proto- 
plasm are round, oval, or crescentic. These bodies are not con- 
tained within other cells. They are much smaller than the tissue- 
cells among which they are found, and they do not exceed one- 
third to one-half the size of a red blood-corpuscle. They are 
distributed irregularlv in the diseased areas in the tissues, and an 
occasional organism may be seen in parts adjacent to the affected 
areas. They have been found in the stomach, the intestines, the 
liver, and the kidneys. In this connection the observations of 
Wagner on the peculiar disease affecting the cobalt-miners of 
Schneeberg are of unusual interest. All persons working in these 
mines for a number of years become affected with a disease of the 
lungs characterized by the formation of nodules, which grow 
slowly and often reach considerable size, metastatic deposits form- 
ing- in other organs. In other localities, where the same metals are 
mined as in Schneeberg, the disease is unknown. It has been sug- 
gested that the disease owed its origin perhaps to the water drunk 
in the mines. The probable infectious nature of lymphosarcoma 
has also been suggested by other authors. 

The only drug which has ever had any effect upon this form of 
sarcoma or any other form is arsenic. Fowler's solution, adminis- 
tered in doses reaching as high as 20 drops a day, given by the 
mouth and subcutaneously and as parenchymatous injections in the 
tumors, cured a certain number of cases of lymphosarcoma. In the 
case of an old man with a sarcoma of the neck the size of a small 
cocoanut the use of Fowler's solution produced a temporary remark- 
able diminution in the size of the tumor. This is the only case in 
which the writer has ever obtained any decided result from the use 
of the drug. 

Some few years ago Fehleisen experimented with cultures of the 
erysipelas coccus, inoculating cases of sarcoma and carcinoma. 
Several tumors were made to disappear in this way, but after one 
or two fatal results had been obtained by certain experimenters the 
method seems to have been abandoned (p. 400). 

This method has been revived by Sprouk of Utrecht and Coley 



SARCOMA. 735 

of New York. Coley' s attention was drawn to this investigation 
after observing the cure of a case of inoperable sarcoma of the neck 
by an attack of erysipelas. Since 1891, Coley has been investigat- 
ing the antagonistic action of erysipelas cultures upon malignant 
growths, more particularly on sarcoma. The first series of cases 
were ten in number (six sarcoma, four carcinoma), and they were 
treated by means of repeated injections of pure living bouillon cul- 
tures. In but four of these cases w T as actual erysipelas produced, 
although cultures of marked virulence were used. In two of the 
cases where erysipelas did occur the tumor disappeared completely 
— the one three years and the other two years later — and both 
patients are alive and in good condition at the present time. Most 
of the other cases showed more or less improvement. 

To avoid the dangers of an attack of erysipelas, Coley experi- 
mented with the toxines alone, made with bouillon cultures steril- 
ized by subjecting them to a temperature of ioo° C. Of this fluid 
1 to 3 C.c. were injected into the tumors, with the effect of pro- 
ducing all the symptoms of actual erysipelas; which symptoms, 
however, disappeared within twelve to twenty-four hours. The 
effect upon the tumors was similar in character, but less marked 
than when living cultures were used. 

Cultures prepared without heat grown three weeks in bouillon, 
then filtered through porcelain, and preserved by the addition of 
thymol, were next used. The great difficulty lay in the weakness 
of the preparation, necessitating the injection of large doses to pro- 
duce a marked reaction, without which no great decrease in the 
size of the tumors occurred. 

Utilizing the principle that one germ frequently has the power 
to increase the virulence of another when associated with it — this 
being especially true of the bacillus prodigiosus — the toxines of 
this germ were prepared in a similar manner and used in conjunc- 
tion with the erysipelas toxines in doses of .2 to .5 C.c. The results 
were satisfactory. The effect was not only to intensify greatly the 
reaction, but careful experiments with the toxines, singly and com- 
bined, in a large number of cases, confirmed the belief that the 
curative action of the erysipelas is likewise greatly enhanced by 
the prodigiosus. 

Coley recently reported 35 cases of inoperable malignant tnmors treated 
by these combined toxines: 24 of these cases were sarcoma, 8 carcinoma, 3 
sarcoma or carcinoma. In 5 cases of sarcoma there is, according to him, a 
reasonable hope of permanent cure, and in most of the others there was 
marked improvement. All the cases were inoperable, and in all the diag- 



73^ SURGICAL PATHOLOGY AND THERAPEUTICS. 

nosis was confirmed clinically and microscopically by eminent surgeons and 
pathologists. During the past year the proportion of the toxines has 
greatly been improved, and the filtration method is no longer used. Better 
results have been obtained by utilizing the toxines contained in the dead 
germs as well as the soluble products, and experiment has shown that heat- 
ing the cultures one hour at 58 C. is sufficient to render them sterile. 
Further improvement is due to Mr. B. H. Buxton, who suggested growing 
the two germs together in the same bouillon. (See Appendix.) 

The experience of many prominent surgeons with this method 
of treatment has not been satisfactory. There is little doubt that 
it is of little if any value in the treatment of carcinoma. The 
fact that a considerable number of cases of sarcoma have been 
benefited by this treatment, and that a few have been cured, 
renders it desirable to experiment further in this direction. 



XXXI. BENIGN TUMORS. 

The members of the group which are now about to be studied 
vary greatly from one another in their anatomical peculiarities, 
and some are quite complicated in their structure. They possess 
one characteristic, however, in common — in that they do not tend 
to recur after removal. Many of them at times show a tendency to 
become malignant, often after a period of prolonged quiescence, 
but this tendency is due to a change of anatomical structure to that 
resembling one of the forms of malignant tumors. 

i. Adenoma. 

An adenoma is a tumor consisting of new-formed gland-tissue. 
Quite a number of tumors are classified as adenomata by some 
authors, but they are rejected by other authors, who insist that the 
growth must consist of a new formation of gland-tissue only; so 
that there is at present much confusion as to the precise place 
which many tumors should occupy. Many small growths contain 
a glandular structure which is clearly nothing more than hyper- 
trophy of pre-existing gland-tissue, due, probably, to an inflamma- 
tory process, and they should not, therefore, be regarded as adeno- 
mata. Many of the cysts that form in glands present the appear- 
ance of a tumor, but they are simply the result of an obstruction 
of the gland-ducts. A classification of the pure adenomata cannot 
be attempted beyond the general statement that the gland-struc- 
ture of which they are composed consists either of acini or of 
tubes, as one or the other of these component parts of a gland 
usually predominates in the new growth. 

Adenoma is found in the breast, the skin, the mucous mem- 
branes, the kidney, and the liver. It is, in fact, quite widely 
distributed, although not a common form of tumor. The typical 
adenoma is a benign tumor, notwithstanding there are certain types 
of growth where the adenoma seems to merge into the carcinoma, 
and it has therefore been supposed that certain forms of adenoma 
should be regarded as malignant. These growths properly belong 
in the category of cancer. The criterion of a benign adenoma is 

47 737 



738 SURGICAL PATHOLOGY AND THERAPEUTICS. 

the presence of the membrana propria which separates the invest- 
ing epithelium from the surrounding connective tissue. Combina- 
tions with other forms of growth not infrequently occur, owing to 
development of the stroma of the gland-structure. There are 
obtained in this way forms known as adenoma fibrosnm, myxoma- 
tosum, or myxo-adenoma and fibro-adenoma, as they are called 
by different writers. Cysto-adenoma occurs not infrequently, par- 
ticularly in the breast and the ovary. Adenoma occurs both 
as a congenital tumor and as one developed during early life, 
but it may also be found occasionally during all the periods of 
adult life. 

Pure adenoma of the breast is a rare growth. Gross was able 
to collect but eighteen examples. He describes it as an ovoid or a 
nodulated tumor of hard consistence, occasionally cystic, and 
limited by a distinct fibrous capsule. On section the surface is 
milky-white in color and dotted with small orifices. It is a 
solitary growth, and it generally originates in the upper and inner 
quadrant. Its development is slow, and it does not attain a large 
size. When examined under the microscope it is found to be 
composed of ducts or of acini containing an epithelium which is 
usually arranged in an orderly manner, closely resembling that 
seen in a normal gland. 

The interstitial tissue of the mammary gland is often the seat 
of a growth that gives rise to tumors of considerable size. The 
gland-structure found in these tumors is always a prominent fea- 
ture, but many writers regard them as belonging to the fibromata 
or to the myxomata, according as their tissue is fibrous or mucous 
in character. These tumors often attain great size, and present 
striking peculiarities which have attracted much attention, opin- 
ions varying greatly as to their character. They have been called 
by Paget "proliferous cysts," and the terms adenocele and intra- 
canalicular papillary fibroma have also been applied to them. 
They are seen most frequently in young women from fourteen to 
nineteen years of age, and they first appear in the upper and outer 
quadrant of the breast. Being surrounded by a capsule, they are 
more or less movable, and they appear to be situated just beneath 
the skin, but after removal a deep hole is left in the mammary 
gland, which has been cut into in many places during the operation. 
Occasionally they grow to immense size. These tumors are seen 
in elderly women, and they have taken many years, perhaps half 
a lifetime, to develop. A recent writer, Schimmelbusch, called 
these tumors " fibro-adenoma," and this name seems to the writer 



BENIGN TUMORS. 739 

most appropriate, for there can be no doubt that there is a consid- 
erable new formation of gland-tissne. The cut surface is most 
characteristic, showing a lobnlated growth dotted over with numer- 
ous small and tortnons slits. Occasionally this formation is a most 
complicated one, and numerous papillary growths may be turned 
out from cyst-like cavities. This formation is apparently due to 
the peculiar way in which the fibrous tissue has developed. Micro- 
scopically, there is found a fibrous tissue surrounding these glandu- 
lar cavities, which are lined with a more or less columnar-shaped 
epithelium (Fig. 106). It is not always possible to say beforehand 




Fig. 106. — Fibro-adenoma of Breast (oc. 4, obj. A.). 

whether the growth in question is or is not a benign one, as the 
interstitial tissue is occasionally sarcomatous (cystosarcoma). The 
writer has removed quite a number of such tumors, but has never 
observed a recurrence. 

Schimmelbusch also describes as cysto-ade?toma a diffused en- 
largement of the mammary glands studded with numerous small 
cysts containing a dark-colored fluid. Both breasts are said to be 
affected in the majority of cases. His description corresponds with 
that condition usually described as chronic mastitis with cyst-forma- 
tion. As the epithelial structures of the gland actively participate 
in the growth, as may be shown by a careful microscopical exam- 



74° SURGICAL PATHOLOGY AND THERAPEUTICS. 

ination, the growth should be regarded essentially as glandular. 
These cysts sometimes assume considerable size, and a breast thus 
affected may thoroughly be disorganized. A microscopical exam- 
ination shows that there is an epithelial growth, and that the cyst- 
formation is caused by proliferation of the cells of the gland. The 
acini are increased in number — a condition resembling the changes 
observed during lactation. The epithelial layer is at first single, 
but subsequently the cells heap upon one another and dilate the 
acinus, and a cyst is formed by the subsequent breaking down of 
the cells. These tumors are found most frequently in women 
about forty years of age, and are benign in character. 

Closely allied to this condition is that known as diffused hyper- 
trophy of the breast. In one case, described and illustrated by Bill- 
roth, the coarse appearances of the growth are those of a fibro-ade- 
noma. 

The case of which the accompanying illustration is a portrait (Fig. 107) 
was operated upon by C. B. Porter. The following are the measurements : 
Right breast, largest circumference, 38 inches ; length from chest-wall to nip- 
ple, 17 inches ; circumference at base, 23 inches. L,eft breast, largest circum- 
ference, 28 inches ; length from chest-wall to nipple, 14 inches ; circumference 
at base, 23 inches. The skin was cedematous, thickened, and porky. 
Throughout both breasts were to be felt movable hardened masses the size 
of an orange. Microscopical examination showed the growth to be a diffused 
intracanaliclular fibroma. 

A similar case recently came under the writer's care. The 
breasts were nearly as large as in the above case, but as the patient 
was several months advanced in pregnancy, it was thought best to 
wait and see what influence the birth of the child might have upon 
the growth. After the confinement the breasts diminished to less 
than half the former size. Amputation has been performed in many 
cases with success. 

In the skin adenomata are found both in the sudoriparous 
and in the sebaceous glands. Adenoma of the sweat-glands is 
found in various parts of the body, but principally on the face, 
where it occurs as a small soft tumor of a dirty grayish-white color 
and with a nodular surface. On the cut section are seen coils of 
dilated ducts, from which degenerated epithelium can be pressed. 
At times these little tumors appear to have developed from pre- 
existing sweat-glands; at other times they seem to grow quite inde- 
pendently, one observer having found such a growth in the diploe 
of a cranial bone. It is a rare form of growth. 

Adenoma sebaceum appears on the face in the form of papules, 



BENIGN TUMORS. 



741 



which are usually of congenital origin. According to Crocker, 
the disease is often found on the persons of epileptics, and its 






Fig. 107. — Diffuse Hypertrophy of the Breast. 

true nature is frequently overlooked. This variety of adenoma 
forms roundish, convex papules, ranging from a pin-point in size 
to that of a split pea; these are often bright crimson in color, and 
they are not infrequently associated with small fibromata, such as 
are seen in the "dotage" of the skin of old people. 

Adenoma is found occasionally in the salivary and in the lach- 
rymal glands. The writer has seen a very perfectly-formed ade- 
noma in the parotid gland : it was about the size of a hen's egg^ 
and quite soft in structure, differing markedly in this respect from 
the ordinary parotid tumors. Small miliary multiple adenomata 
are also found in the liver. 

Adenoma of the kidney is found usually in the cortical sub- 
stance, and it is about the size of a bean or a cherry, and often is 
very much smaller. It is usually yellowish or brown in color, and 



742 SURGICAL PATHOLOGY AND THERAPEUTICS. 

frequently contains small cysts which give it a porous appearance. 
Under the microscope are seen coils of tubules containing cells 
which are cylindrical in shape. There is occasionally seen a papil- 
lary variety in which the interstitial tissue forms papillary growths 
that project into cyst-like cavities. The epithelium is more cuboid 
in shape. These adenomata are often surrounded by a capsule. 

Many small superficial growths in the kidney that have been 
supposed to be lipoma are shown by Grawitz to be fragments of 
accessory adrenal glands situated between lobes of kidney-tissue. 
The new-formed cells, like the cortical cells of the adrenal gland, 
contain large drops of fat. These tumors are soft and are yellow- 
ish in color, and they appear to be separated from the adjacent 
kidney-tissue by a capsule. They are often highly vascular and 
contain clots, the result of hemorrhage, which when absorbed lead 
to the formation of cysts: as myxomatous degeneration often takes 
place in them, the whole tumor may in this way be converted into 
a mass of debris containing fat and cholesterin. Under the micro- 
scope sections of these tumors show gland-like structures lined 
with polygonal cells containing fat-drops. 

Adenoma of the testis is a comparatively rare growth. It is 
usually combined with the formation of cysts, and, in fact, the 
majority of cases of multilocular cysts of the testis are developed 
in adenomata. The tumor appears as an enlargement of the testi- 
cle. On section the new formation is found to be lobulated, and 
to consist of a stroma containing cysts and gland-tubes which are 
usually lined with a cylinder epithelium. These glandular struc- 
tures do not appear to be characteristic of any particular form of 
gland. They are more or less dilated and tortuous canals of vary- 
ing shapes and sizes. Occasionally they are filled with masses of 
epithelial cells heaped upon one another, giving the appearance 
of the epidermic clusters seen in epithelioma. The cysts do not 
appear as completely-closed cavities, but they communicate more 
or less freely with the glandular structure of the tumor. 

Adenoma of the testis appears to spring from the seminal ducts 
by growths of the epithelium and the subjacent stroma. All cysts 
of the testicle do not appear, however, to be of glandular origin 
in this sense. Some of them seem to be the result of hemorrhage 
or seem to develop from dilated lymphatics, while others take 
their origin in embryonic remains in the testicle. When multiloc- 
ular cysts have fully developed, they may, by the pressure which 
they exert, destroy the original growth from which they sprang, 
and evidence of their origin is thus lost. Some of the cysts con- 



BENIGN TUMORS. 743 

tain a mucous fluid with gland-cells, and others have atheromatous 
contents containing particles of calcareous matter and pavement 
epithelium. There is found also cartilage in adenoma of the tes- 
ticle. According to Langhans, cartilage forms in the fibrous 
stroma of the tumor. Striped muscular fibre has also been ob- 
served. These tumors are most frequently found between the ages 
of twenty and forty years. They are non-malignant, and they do 
not return after castration, but, inasmuch as cancer is sometimes 
found in combination with adenoma, removal of the testicle 
should always be advised. 

Cyst of the epididymis is known as spermatocele, a condition 
often mistaken for hydrocele. The sac, which is usually quite 
large, contains a milky fluid in which are found spermatozoa. It 
is not developed from any glandular new-formation, but it is a 
a pure retention-cyst. It is a curious fact that while, in the male, 
cysts are found more frequently in the epididymis than in the tes- 
ticle, in the female cysts are more frequent in the ovary, while 
parovarian cysts are less common. Spermatocele occurs most fre- 
quently in the later years of life. 

Mucous polypi may contain well-marked adenomatous struc- 
tures. Such glandular polypi are found in the nose, in the large 
intestine, and, most frequently, in the rectum. One of the most 
perfect types of adenoma which the writer ever examined was an 
adenomatous polyp removed from the rectum of a young man. 

2. Goitre. 

The names goitre, struma, and bronchocele are applied indis- 
criminately to all tumors of the thyroid gland, of which tumors, 
however, there are several distinct varieties, among them being 
true adenoma, which therefore deserves a place here. 

Wolfler gives the following classification of thyroid tumors: 

i. Hypertrophy of the thyroid gland, which is a comparatively 
rare disease. It may occur either at birth or at the period of 
puberty or of pregnancy, and it consists in a uniform increase in 
the normal glandular tissue, so that there are no nodules to be felt 
in any part of the gland. It is soft to the feel, and when vascular 
is compressible. 

2. Foetal adenoma, which is a formation of gland-tissue from 
the remains of foetal structures in the gland. It may exist either 
as a single circumscribed nodule, usually firm and movable, or in 
numerous nodules varying in size from that of a cherry to that of 
an apple. It develops in both sexes at the period of puberty. 



744 



SURGICAL PATHOLOGY AND THERAPEUTICS. 




., 



Fig. 108. — Adenoma of Thyroid Gland. 



3. Gelatinous or interacinous adenoma, which consists in an 

enlargement of the acini by an 
accumulation of colloid ma- 
terial, and an increase in size 
of the interacinous tissue by a 
growth of round-cells (Fig 108). 
This form appears usually in 
the later periods of life, and it 
develops rapidly at the time of 
pregnancy or the change of life. 
At first there is a uniform en- 
largement of the gland, but 
later the different portions grow 
unequally and the gland pre- 
sents great irregularity in 
shape. It is this form in which 
cysts are frequently found (Fig. 
109). 

Wolfler prefers to recognize 

clinically as a special variety 

those tumors which are highly vascular, although this condition 

may accompany any of the above forms. With the increase of 

vascularity there is frequent- 
ly a visible pulsation, and a 
perceptible bruit is heard 
through the stethoscope. 
The tumor may preserve the 
form of the gland and have 
a crescentic or horse-shoe 
shape, or it may be circular, 
surrounding completely the 
trachea. The latter form is 
seen in congenital goitre, 
and it occasionally causes 
death of the new-born child 
by asphyxia. One lobe may 
enlarge and assume various 
shapes, or the tumor may 
consist of a single cyst, 
which in old people occa- 
sionally reaches enormous 

Fig. 109.— Cystic Goitre. size. 



■v*t 




BENIGN TUMORS. 



745 



Goitre may develop ill unusual and unexpected situations in the 
throat, the neck, and the thorax. This mode of development is due 
to the displacement of portions of thyroid-gland tissue during fcetal 
life, and such lobes are known as accessory glands. According to His, 
the middle lobe of the gland is developed in a tract which is directly 
continuous with the foramen caecum of the base of the tongue, and 
this tract is still frequently marked in the adult by the so-called 
"processus pyramidalis," a continuation of the middle lobe to the 
hyoid bone. It is here also that the glandulae supra- and epi- 
hyoideae are found. Such accessory glands may also be found in 
the vicinity of the aorta, at the base of the tongue and behind 
the pharynx, and in the larynx and trachea. 





Fig. i 10. — Accessory Thyroid Gland 
at the Base of the Tongue. 



Fig. hi. — Section of Accessory Thyroid 
Tumor. 



A tumor at the base of the tongue (Figs, no, in, 112) was removed by the 
writer from a woman fifty-two j^ears of age. She first noticed a lump in her 
throat thirty-two years before, since when it slowly and steadily increased in 
size, and at the time of operation it was about the size of a hen's egg. It 
consisted of thyroid-gland tissue. No return was reported two years after 
the operation. 

Mucous cysts are sometimes found in connection with the 
glandula suprahyoidea. They are lined with ciliated or pavement 
epithelium. Retrosternal tumors form as the result of a down- 
ward growth of thyroid tissue from the isthmus. 

Goitre occurs both in man and in animals, and it appears to be 
independent of race. It may be either sporadic, endemic, or epi- 
demic. Endemically, it is found in certain mountainous districts, 



746 



SURGICAL PATHOLOGY AND THERAPEUTICS. 



particularly on the continent of Europe. Epidemically, it breaks 
out in schools and in garrisons. It occurs much more frequently 




Fig. 112. — Thyreoglossal Tract (after His): 71, tongue; U. y, under jaw; 77iorac. y 
thoracic cavity; PP., epiglottis; H.B., hyoid bone; F.c, foramen caecum; T.L., tractus 
lingualis; Th. Th., thyroid gland; Tky?)i., thymus gland; Pa., arytenoid fold. 

in women than in men, and pregnancy seems to be a not infrequent 
cause. Whether the micro-organisms found by Klebs and Bischer 
in water are in reality a cause of the disease in certain cases is not 
yet clear. Acute infective diseases are not without their influence 
in the development of thyroid tumors, as they have been observed 
to form after malarial fever, diphtheria, and scarlet fever. Thyroid 
tumors usually grow extremely slowly, but occasionally an acute 
form is observed; this is particularly true of the vascular type. 
Goitre may prove fatal, owing to the effect of its growth upon the 
trachea, the cartilage of which undergoes degenerative changes. 
In this way it becomes softened, and is easily compressed or 
twisted on its axis by the movements of the head, as a result of 
which sudden death may take place. 

Cysts may be treated, if small, by injection of tincture of iodine. 
Many cases of adenoma have been treated successfully by electrol- 
ysis. If the tumor is excised, a fragment of gland tissue about 
the size of an English walnut should be allowed to remain, other- 
wise myxcedema may develop. Closely allied to myxcedema, 
which may also occur idiopathically, is cretinism. Cretinism is 
characterized by idiocy and imperfect development of the bones,. 



BENIGN TUMORS. 747 

particularly marked in the skull. Cases of myxcedema have suc- 
cessfully been treated with thyroid juice. The parenchymatous, 
but not the cystic, forms of goitre sometimes diminish rapidly in 
size under the use of preparations of sheep's thyroid. Five grains 
a day of the dried gland, or about one-third of one lobe, is a suit- 
able dose to begin with. Some patients can take a much larger 
quantity with benefit, but, on the other hand, a remarkable sus- 
ceptibility to the toxic effects is occasionally present. 

It is important to say a word about the relation between ordi- 
nary goitre and that form characterized by the signs and symptoms 
of the so-called "Graves's disease" or "exophthalmic goitre," 
though the subject is so complex that only the broad outlines can 
be indicated. It is, in the first place, noteworthy that ordinary 
goitre is apt to be attended with nervous symptoms, of which 
tachycardia, or a tendency to palpitation, is the chief. It is a 
matter of great doubt what is the relation in which goitre and 
nervous symptoms stand to each other. Wette thinks that local 
nerve-irritation plays an important part, but he rather inclines to 
a theory which has been advanced of late (Mcebius and others) that 
an increased or perverted thyroid secretion, acting as a poison, has 
to do a good deal with the production of the symptoms of typical 
Graves's disease. 

If the matter is looked at from another side, it will be found 
that Graves's disease is strongly associated with other neuropathic 
conditions, and that it occurs under conditions of nervous excite- 
ment. Some writers (Greenfield; Maude) believe that even when 
Graves's disease arises through nervous excitation thyroid-poison- 
ing forms an important, if not a necessary, factor. This theory is 
not yet substantiated or even made highly probable, and the more 
conservative view is that the enlargement of the thyroid is on the 
same plane with the other symptoms in the first instance, but that 
it may become secondarily a source of mechanical irritation or of 
poisoning, or both. 

Thyroidectomy has been performed more than fifty times within 
the past few years, mainly by German surgeons, for the relief of 
Graves's disease. The eventual results, on the whole, are very 
encouraging, but severe symptoms are apt to show themselves 
during the first days after operation, occasionally leading to death. 
It is probable that the extreme irritability of the nervous centres 
of these patients makes thyroidectomy a more serious operation 
than in cases of ordinary goitre. Putnam suggested that these 
symptoms may be due in part to poisoning with a thyroid secre- 



748 SURGICAL PATHOLOGY AND THERAPEUTICS. 

tion squeezed out during the operation and the healing of the 
wound. 

The writer has operated upon two cases of exophthalmic goitre. 
In the first the temperature rose to 106 the first evening, and the 
pulse to 204. On removing the dressing a small quantity of thy- 
roid juice was found upon it. The wound healed by first intention, 
and the patient was benefited by the operation. In the second case 
no bad symptoms followed the operation at first, but on the fourth 
day the temperature, which had been normal, suddenly rose, the 
pulse became extremely rapid and weak, and the patient died in a 
few hours. All the cases of glandular and cystic goitre which the 
writer has operated upon have recovered without bad symptoms, 
although occasionally an acceleration of the pulse has been noticed 
for a few days. 

3. Cystoma. 

Cysts of the ovary were formerly supposed to be developed 
from a Graafian vesicle by distention of such a cavity with fluid. 
Such dropsical effusion may occur to a limited extent partly as the 
result of inflammatory conditions. Small cysts may develop also 
in the corpus luteum. True cystoma is, however, epithelial in 
origin, and in many cases it begins as an adenoma. It is devel- 
oped from an ingrowth of epithelium into the stroma of the ovary, 
very much in the same way that the Graafian vesicle is formed. 

There are two principal varieties of ovarian cysts: the simple 
cystoma or cysto-adenoma, and the papillary cystoma. In the 
wall of the simple cystoma are numerous follicular depressions 
lined with cylinder or ciliated epithelium, and near them are small 
cysts lined with similar epithelium. By this ingrowth of epithe- 
lium into the wall of the cyst new cysts may be developed and the 
tumor may become multilocular. Parts of the tumor may dis- 
tinctly be adenomatous instead of cystic. Such growths are occa- 
sionally found in the walls of large cysts or in the septum between 
two cysts. The papillary cystoma is characterized by the presence 
of a warty or papillary growth into the interior of the cyst. These 
growths show the greatest difference in their development. The 
wall of the cyst may be covered with numerous small warty 
tumors, or the cyst may be filled with a cauliflower mass. In rare 
cases the outer surface of the cyst is covered with a similar growth. 
There may also be an ingrowth of the epithelium into the stroma 
and glandular structures, thus producing a combination of ade- 
noma with papilloma. The epithelium of the papillary cystoma 



BENIGN TUMORS. 749 

is usually ciliated epithelium. Occasionally a limited metastasis 
is found, the peritoneum being studded with papillary growths. 
It has been suggested that these papillary growths may develop 
from the parovarium, as they are often found within the broad 
ligament, but it is probable that in the majority of cases they 
originate in the same way as the simple or glandular cystoma. 

The material contained in the cysts may vary greatly in color and 
in consistence. It is usually of a mucous character, but it may be 
gelatinous. It appears to be developed from the cells that line the 
wall of the cyst, and it is either a product of their secretion or it 
may be the result of degenerative changes in the cells. The cells 
may undergo not only colloid degeneration, but also fatty degen- 
eration and necrosis. Necrosis of the cyst-wall may take place, 
and sometimes suppuration may occur. Calcareous degenera- 
tion of the cyst-wall is also observed. It is probable that cys- 
toma of the ovary is not of fcetal origin, but that the epithelial 
growths from which they are developed may begin at any period 
of life. 

Ovarian cysts are for the most part benign, but, as has been 
seen, the papillary form may be accompanied by peritoneal 
growths. The papillary growths in the cyst may break through 
and appear as cauliflower excrescences on the surface, and in this 
way there may be a gradual metamorphosis into a carcinoma. 
Cysts of the broad ligament are not of new formation, but they 
are caused by an accumulation of secretion in the gland-tubes of 
the parovarium. They develop probably from the remains of the 
Wolffian bodies. 

The ovary at times also contains cysts, which are either in part 
or are wholly made up of dermoid structures. These cysts may 
contain only dermal structures, or a great variety of tissues may 
be found in them, such as bone, teeth, cartilage, muscle, or 
mucous membrane, glands, nerves, etc. Tumors of the latter 
class are called "teratoma." 

The commonest forms are the dermoid cysts and the simpler 
forms of teratoma. They are usually found on one side, but they 
may occur simultaneously in both ovaries. They are usually 
smaller than the adeno-cystoma, growing not larger than an apple 
at first, but they may occasionally reach the size of a man's fist or 
head. Several varieties can be recognized, according to the more 
or less complicated nature of their construction. The epidermoid 
cyst has a wall of connective tissue lined with epidermis, but it 
possesses no other attribute of the skin. The contents in this case 



750 



SURGICAL PATHOLOGY AND THERAPEUTICS. 



are, distinctly, epidermic scales, which may be rolled up in firm 
masses or are more or less soft or soapy in appearance (Orth). 
The commoner form is the dermoid cyst. In this form of cyst the 
wall is made up of skin containing small and ill-defined papillae, 
but rich in hair-follicles and sebaceous glands. Even the erector 




Fig. 113. — Dermoid Cyst of Ovary, showing hair, tooth, and adipose tissue. 

pili muscle and the sudoriparous gland are often found. The hair 
is partly free and partly rolled up into thick balls, or it is still 
attached to the walls. A large mass of sebaceous material is also 
found in these cysts (Fig. 113). 

The simpler forms of teratoma are dermoid cysts containing 
bone and teeth. The bone appears as a series of plates in the wall 
of the cyst, giving to the touch the feel of an infant's head. The 
teeth, which are not always well formed, are arranged without 
order. The complicated teratoma may contain, in addition to the 
above-mentioned structures, cartilage and glands, such as mucous 
and salivary glands, mucous membrane with cylinder or ciliated 
epithelium, smooth and striped muscular fibre, nerves and cerebral 
substances, portions of eyes, fingers with nails, mammas, etc. It 
is probable that these more complicated forms of cystic growth 
have the same origin as the cysto-adenoma of the ovary, and they 
result from the activity of the germinal cells (Orth). 

The growth of dermoid cysts is slow, and they are generally 
first observed at the period of puberty, although not infrequently 
found in young children. Combinations of dermoid cyst with 
adeno-cystoma are occasionally observed, Thomson reports a case 
of dermoid cyst of the bladder containing hair, which cyst he re- 



BENIGN TUMORS. 751 

moved. It was a pedunculated growth, and it was undoubtedly 
vesical, and not expelled from some ovarian source through the 
urinary passages, as sometimes occurs. 

Dermoid cysts are found also in regions of the body quite 
remote from the ovary. The so-called "orbital wens" are true 
inclusion of skin of a congenital origin, as are also some of the 
cysts in the neck. Many of the cysts in the latter region are due 
to imperfect closure of the branchial clefts, and they have been 
called by Senn "branchial cysts." This author recognizes — 1, 
mucous cysts; 2, atheromatous cysts; 3,- serous cysts; and 4, hae- 
matocysts. 

Many of the so-called u ranula cysts" about the base of the 
tongue belong to the class of mucous cysts. The atheromatous 
cysts are. situated near the hyoid bone, and they appear as tumors 
bulging out from beneath the lower jaw. They do not contain 
hair or sebaceous material, but they are filled with an atheroma- 
tous substance containing cholesterin crystals. The cyst is of the 
epidermoid type. 

The serous cysts correspond to what is usually known as hydro- 
cele of the neck. These cysts are single or are multilocular, with 
a thin membranous wall lined with pavement epithelium. They 
are found anywhere in the neck, within the area of the branchial 
clefts, between the lower jaw and the clavicle. These branchial 
cysts are often found in children, but are not infrequently seen in 
adults also. The haematocysts are of the same nature, the blood 
mingling with the serous contents from minute hemorrhages from 
the cyst-walls. 

4. Papilloma. 

Many writers place this form of growth among the fibromata, 
but certain forms — particularly those seen on mucous membranes — 
have so marked an epithelial character that it would be incorrect 
to recognize the stroma as the characteristic feature of the disease. 
This type of the papilloma is found in the papillae of the skin and 
the mucous membrane. It consists of a papilla containing a vas- 
cular connective tissue, and is covered with epithelial cells. 

The connective- tissue portion of the growth may consist of a 
single stem or of a trunk with numerous branches. The tissue 
consists ordinarily of nbrillated connective tissue, and it is not 
infrequently infiltrated with small round cells. The vascular sup- 
ply varies greatly, but in certain forms, such as the villous growth 
from mucous membranes, it may be very abundant. The epithe- 



752 SURGICAL PATHOLOGY AXD THERAPEUTICS. 

Hum covers each villus separately, but occasionally there may be 
an epithelial covering extending over several villi. 

There are two forms of papilloma, the hard and the soft. The 
hard form occurs on the skin and the mucous membranes. The 
ordinary wart consists of hypertrophy of several papillae with their 
epithelial coverings. It need not, therefore, strictly speaking, be 
called a papilloma, as there is no new formation of papillae, but it 
is usually classed with these growths. The venereal wart (condy- 
loma acuminatum) is, however, an example of a true papillomatous 
growth. The hard form of papilloma is found in the mucous mem- 
branes upon the lips, in the mouth, the uvula, the nasal cavity, in 
the larynx, the urethra, the vagina, the labia, the cervix uteri, and 
the bladder. It has a firm, well-developed stroma, and it is covered 
with layers of pavement epithelium. The soft papilloma is cha- 
racterized bv the formation of long, delicate, single or branched 
villi, the surface of which is covered with a cylinder or pavement 
epithelium of one or more layers in thickness. This cylinder 
may cover several villi, and may give to the surface of the growth 
a smoother appearance than is seen in the more typical velvety 
villous tumors. These growths may spring from one stem or they 
may be multiple, covering a large surface of mucous membrane. 
They are very vascular, and the capillaries have ampulla-like dila- 
tations, which account for the extensive and repeated hemorrhages 
that are liable to occur. 

The soft, villous papillomata are found in the bladder, in the 
stomach and intestine, particularly in the colon and duodenum 
(Birch-Hirschfeld), and also in the uterus. Some writers distinguish 
those papillomata found on the membranes of the brain from the 
other forms, as they are here covered with endothelium. The 
Pacchionian bodies are the types of this variety; they are found in 
the parietal region and also at the base of the brain. Springing 
from the dura, they may grow into the venous sinuses (Klebs). 
Papillomata growing on the skin and the mucous membranes may 
be congenital or be acquired. They appear to be the result in the 
latter case of chronic irritations, as catarrhal affections. 

Papilloma may occur at any period of life. Watson, in a col- 
lection of 89 cases, found 59 in males and 30 in females. In the 
male, 21 cases occurred between the ages of sixty and seventy, and 
35 between the ages of thirty and sixty. In the female, 17 occurred 
between thirty and forty, and 12 after fort}'. Papilloma may be 
multiple or single, sessile or pediculated. Thompson describes the 
hard variety as fibro-papilloma, and the soft form as fimbriated 



BENIGN TUMORS. 753 

papilloma. He reports several cases of fibro-papillomata removed 
from the bladder through the median incision in the male and 
through the urethra in the female, all of which cases made a good 
recovery with permanent cure. The tendency of papilloma of the 
bladder to bleed is one of its most marked clinical features. Papil- 
loma of the bladder may be combined with carcinoma, in which 
case characteristic epithelial cells are found in the base of the 
tumor in the bladder-wall. 

Papillomata of the larynx occur more frequently than all other 
forms of benign tumors of this region. They are situated in the 
large majority of instances on the vocal cords, usually in the 
anterior portion of the larynx. In rarer cases they are found upon 
the ventricular bands, the ary-epiglottic folds, and the epiglottis 
(Bosworth). As a rule, they confine themselves to the supraglottic 
portion of the larynx in adult life, although in children they 
occasionally extend below the cords. They are usually sessile in 
character, though occasionally pedunculated. They may occur 
singly or in groups, and they vary in size from a millet-seed to a 
growth more or less completely filling the supraglottic laryngeal 
cavity. They become a growth of great clinical importance, owing 
to the obstruction which they offer to the air-passages. Papilloma 
of the soft palate and the uvula may occasionally grow to consider- 
able size, but it does not, as a rule, give rise to serious symptoms. 
Newman describes a papilloma of the oesophagus situated on the 
anterior wall immediately behind the cricoid cartilage, which 
papilloma caused during life considerable obstruction to swal- 
lowing. 

5. Fibroma. 

Fibrous tissue occurs in nearly all tumors, and in some it forms 
a very considerable portion of the growth, as in the tumors already 
described. It occurs as a mixed form with other growths, as in 
myxoma, sarcoma, neuroma, etc. Fibroma occurs in two principal 
forms, which correspond in character with the two varieties of con- 
nective tissue found in the body — namely, the hard and the soft or 
areolar fibroma (Birch-Hirschfeld). 

The hard fibroma consists of bundles of fibres closely packed 
together, interspersed with numerous connective-tissue corpuscles. 
The relation in the number of cells to the intercellular substance is 
characteristic of this tumor (Fig. 114). When the cells begin to ex- 
ceed in number the intercellular substance, there are presented con- 
ditions approaching those found in sarcoma. A fibroma is usually a 

48 



754 



SURGICAL PATHOLOGY AND THERAPEUTICS. 



well-defined nodular growth, showing a tough tissue when cut open, 
and containing very few blood-vessels, and is situated principally in 
trie subcutaneous cellular tissue, in the connective tissue of the skin, 
of the muscles, periosteum, nerve-sheaths, and serous membranes. 




Fig. 114. — Fibroma. 

Fibrous tumors occur in the interstitial tissue of organs, such as 
the kidney, the female breast, and in the liver, the spleen, and 
the ovaries. Many of the polypoid growths found on mucous 
membranes must be regarded as fibromata. 

One of the commonest seats of fibroma is the skin. The warty 
growths, although largely composed of fibrous tissue, are usually 
classified with the papillomata. A variet}^ which has lately excited 
much attention is seen in the multiple fibromata of the skin. They 
occur sometimes in enormous numbers, covering nearly the whole 
surface of the body, and associated with them are often pendulous 
tumors of considerable size. Such growths in the skin were called 
"fibroma molluscum " by Virchow, but V. Recklinghausen called 
attention to the fact that these growths take their origin from the 
fibrous sheaths of the nerves and the various channels, such as the 
sweat-ducts and the hair-follicles. In his opinion, many of these 
tumors should be regarded as neurofibromata. He found the papil- 
lary layer of the skin quite unaffected. In many of the cases of 
multiple fibroma reported it was found that tumors connected with 
the nerve-trunks also existed. Such was the condition found in a 
case reported by Payne, who, however, observed no actual connec- 



BENIGN TUMORS. 755 

tion between the fibromata of the skin and nerve-fibres. Payne 
explains the coexistence of nerve-fibres and skin fibroids on the 
supposition that, inasmuch as both the epidermis and the nervous 
system arise from the epiblast, these two structures have a deep- 
lying connection which makes them homologous parts. 

Keloid {yj t h' h a claw), which is a fibroma of the cutis vera, may 
develop spontaneously or in a scar. Two varieties are recognized 
— the true and the false keloid. There is, however, a tendency 
among writers at the present time to disregard this distinction. 
True keloid has always been considered as a spontaneous new for- 
mation in the corium independent of pre-existing wound. It is 
now supposed that true keloid may take its departure from some 
minute scar which has escaped notice. 

The typical true keloid is situated over the sternum, and it 
appears as a raised elongated growth, frequently with claw-like 
prolongations at either end. Its surface is smooth and shiny, and 
the color red like that of a hypertrophied scar. It grows to a cer- 
tain point, reaching the length of about two inches, and then re- 
mains stationary. There is no tendency to ulceration. It is an 
extremely rare disease, and the writer has seen but two examples. 
According to Hebra, it is found once in two thousand cases of skin 
disease. It is not painful, but it gives rise to an itching, prickling 
sensation. It rarely disappears, and if excised it returns promptly. 

False keloid, which is a growth similar in color and consistency 
to true keloid, develops from a scar, no matter in what part of the 
body. It varies greatly in size, and it may be of any shape. A 
favorite seat is the lobe of the ear after puncture, and it is also 
found frequently on the chest-wall. It occasionally springs from 
acne-pustules, and in this case it is multiple. Keloid is said to be 
found rarely on the mucous membrane. Verneuil reports a case 
of keloid of the conjunctiva. Ziemssen reports the case of an 
individual who had one hundred and five keloids. 

True keloid appears to be a disease of adult life, but false keloid 
may appear at any age. There seems to be a keloid disposition in 
certain families and individuals, and the peculiarity of the African 
race in this respect is well recognized. False keloid grows to a 
certain point, remains stationary for many years, and finally flat- 
tens somewhat and becomes paler. In negroes, although it attains 
unusually large size, it is said eventually to disappear entirely. 

Hutchinson observed in a negro an extensive keloid growing in 
the cicatrix following a burn. After the keloid developed numer- 
ous small scars, which had existed before, began also to indurate. 



756 SURGICAL PATHOLOGY AND THERAPEUTICS. 

This occurrence suggested to Hutchinson the probability that in 
some way the keloid patch had shed into the blood infective mate- 
rial which had the power of developing only scar-tissue. 




Fig. 115. — True Keloid (longitudinal section). 

Microscopically, the tumor, both in true and in false keloid, is 
found to be composed of bundles of fibres running horizontally 
some little distance beneath the surface of the corium and arranged 
parallel with the long axis of the tumor. In true keloid the pa- 
pillae with their normal covering of epidermis are seen above the 
growth (Fig. 115), whereas in false keloid only scar-tissue exists 
over the tumor. In true keloid, however, when there is consider- 
able pressure from growth the papillae are flattened out. The 
fibrous growth so characteristic of keloid can be traced to the walls 
of the blood-vessels in the vicinity. It is probable that the fibrous 
tissue develops from the outer walls of the blood-vessels, as the 
writer has been able to observe a round-cell growth and also fusi- 
form cells in the adventitia. As bundles of fibres in this way form 
around the arteries, the tissue of the corium is gradually com- 
pressed by them, and the different bundles thus uniting form the 
keloid. 

The origin of these tumors from the walls of blood-vessels sug- 
gests the possibility of the existence of muscular tissue at some pe- 
riod in the development of these growths, and it is not improbable 
that some forms of keloid may be classed with the fibromyomata. 




BENIGN TUMORS. 757 

One case is reported of a spontaneous growth in the face having 
returned, after excision, in the scar and in the points of suture, 
and being subsequently 
cured by hypodermic in- 
jections of ergot. 

Pendulous tumors occur 
in the skin, and they some- 
times attain a large size. 
Some of them may develop 
from scars; others are 
spontaneous growths which 
lie in overlapping folds. 
Closely allied to this group 
of tumors is dermatolysis, 
but this term should be 

applied Strictly to a loose Fig. n 6.— Nasopharyngeal Fibroma (Sp. 1247-2, War- 
fold of skill containing 110 ren Museum). 

fibrous tissue. 

The enormous growths of elephantiasis depend upon the forma- 
tion of a fibrous tissue similar to that seen in fibroma. It is, how- 
ever, a diffuse growth, with an etiology peculiarly its own, and it 
is not now classed with this form of tumor. 

Some forms of fibroma arise from the tissue of the periosteum. 
A striking example of this form of tumor is the nasopharyngeal 
polyp, which is often a pure fibroma springing from the base of the 
skull. When composed of fibrous tissue the polyp is a perfectly 
benign tumor, and it does not recur after removal. The accom- 
panying illustration (Fig. 116) shows such a growth which had 
involved the nasal passage and the pharynx and had grown out- 
ward beneath the zygoma. A lobe had also penetrated the antrum 
and perforated the hard palate. It was therefore so intimately 
connected with the superior maxilla that it was decided to excise 
that bone. The patient, who was a boy aged fourteen, has re- 
mained well for several years since the operation. 

Fibrous polyps are found also growing from the walls of the 
large intestine, taking their origin from the connective tissue of 
the submucosa. They are found occasionally also in the rectum. 
Another form of tumor which is occasionally fibrous is the intra- 
canalicular papillary growth in the breast, in which case the inter- 
stitial tissue of the tumor is purely fibrous. Its association with 
sarcoma and myxoma is mentioned elsewhere. 

The soft fibroma contains loose areolar connective tissue, the 



75 8 SURGICAL PATHOLOGY AND THERAPEUTICS. 

spaces of which are filled with serous fluid, which gives the ap- 
pearance of cedematous tissue. Occasionally large cyst-like spaces 
are found in them. It may be found in the skin, in the subcuta- 
neous connective tissue, in the intermuscular tissue and the peri- 
osteum, and, according to Birch-Hirschfeld, even in bone. A 
familiar type of this soft fibroma is the mucous polyp, which, in 
many cases, is purely fibrous. It has sometimes been called the 
"cedematous fibroid." Many of the cases of molluscum verum 
of the skin belong in this class. 

A fibroma has a very slow growth. It may remain for a long 
time without any change whatever, and then suddenly take on a 
rapid growth. In such cases there is probably a transformation 
into sarcoma. Fibroma occurs in both sexes and in various races, 
and it may begin in early life. It often undergoes calcification 
and sometimes fatty metamorphosis. 

6. Myxoma. 

Myxoma (/i^«, mucus) is a tumor composed of tissue which 
finds its type in mucous tissue. It corresponds to the fibrocellular 
tumor of Paget. This tissue is found in abundance in embryonic 
life, and it is the structure from which adipose tissue is subse- 
quently formed. It is seen also in the foetal cord. In the adult it 
is found in the vitreous humor, and it is observed also as a degen- 
erative change in adipose tissue and in the medulla of bones of 
old people. 

Myxoma is closely allied, therefore, to lipoma, and indeed 
combinations of both structures in the same tumors are not infre- 
quently seen. Tumors of this nature which grow from adipose 
tissue should therefore be considered fairly homologous. There is 
also a semi-homologous type in the myxomas arising from the 
perineurium, the neuroglia being closely allied also to the mucous 
tissue. 

Histologically, mucous tissue is found in two forms. In one 
the cells are round and are imbedded in a transparent intercellu- 
lar substance. In the other form the cells are long and spindle- 
shaped, or are stellate with long prolongations which anastomose 
with one another. The substance of which the matrix of the 
tumor is composed is mucin, which coagulates on the addition of 
alcohol, foiming a thread-like or membranous deposit. There is a 
network thus formed somewhat like that seen in fibrin (Fig. 117). 
Myxoma may occur alone or in combination with other tissues. 
A pure myxoma with very few cells in it, consisting principally of 



BENIGN TUMORS. 759 

transparent intercellular substance, is known as a hyaline myxoma. 
If there is a considerable amount of fibrous tissue in the intercel- 
lular substance, it is known as myxoma fibrosum. A very cellular 
type is called "myxoma inedullare." Myxoma may also be 
combined with cartilage and adipose tissue, and at times may be 



4 • # 



£2, 


t 








43/?-: 




K 


% 












IB 


% 


% 


9 


vSg) 


V 
1 


* 
m 



Fig. 117. — Myxoma (oc. 4, ^ oil-im.). 

very vascular. The term myxosarcoma is used when in sarcoma 
the intercellular substance is of a transparent character and 
contains mucin. 

Myxoma occurs most frequently w 7 here there are deposits of fat 
or of loose connective tissue, as in the thigh, the back, the hand, 
and the cheeks, or at the angle of the jaw, or in the breast, the 
labium, or the scrotum. It is observed also in the placenta, and it 
is interesting to know that myxoma may occasionally develop in 
later life from the navel, as if it had formed from foetal remains of 
the cord. 

Myxoma may occur in combination with enchondroma in large 
tumors of the bone, taking its origin apparently from the tissue 
of the medulla. Myxoma occasionally attains considerable size, 
and it has then a w T ell-marked lobulated structure. The writer 
removed one, about the size of a cocoa-nut, from the popliteal 
space. This tumor is occasionally found growing on the spinal 
arachnoid and in the ventricles of the brain, and even in the 



760 SURGICAL PATHOLOGY AND THERAPEUTICS. 

cerebral substance. The pure forms are, however, rare here. The 
tumor more frequently found is a myxoglioma or a myxosarcoma 
(Knapp). The intracanalicular papillary tumor of the breast is 
often myxomatous. 

A not infrequent seat of myxoma is in the nerves, where it 
grows from the perineurium and presses the nerve-fibres apart, 
and develops as a spindle-shaped or a cylindrical tumor. On the 
mucous membranes these tumors appear in the guise of polyps, 
particularly in the nose. Similar polyps have been found also in 
the uterine cavity. Myxoma is essentially a benign tumor, 
although it often assumes importance, owing to its size, to the 
readiness with which it breaks down, and to the difficulty of re- 
moving it thoroughly in inaccessible regions. Many of the myx- 
omata of nerves are, however, undoubtedly malignant. Virchow 
reported several such examples, and metastases are reported as fol- 
lowing the development of myxoma in the labium. The possibil- 
ity that myxoma may be combined with sarcoma and carcinoma 
should always be kept in mind. 

7. Lipoma. 

A lipoma is a tumor consisting of adipose tissue. It is a soft or 
a moderately firm lobulated tumor, and in its structure closely 
resembles the subcutaneous adipose tissue, consisting of lobules of 
fatty issue separated by fibrous septa of greater or lesser thickness. 
More rarely it occurs as a smooth globular mass. Its circumfer- 
ence is sharply limited by a capsule which is more or less loosely 
attached to the surrounding parts, so that it can readily be enu- 
cleated. 

The true lipoma must be distinguished from diffuse accumula- 
tions of fat in different parts of the body in the same way that 
fibroma is distinguished from elephantiasis. Such are the diffuse 
formations of adipose tissue in the mammary glands and in the 
abdominal walls in cases of obesity, the accumulation of fat around 
the kidney, or the polypoid growths on the joints (lipoma arbor- 
escens). Masses of fatty tissue occur on the fingers and toes in 
consequence of disease of the spinal cord, and great development 
of the adipose tissue occurs congenitally in the extremities in cases 
of gigantism. There are, however, certain diffuse forms of lipoma 
which deserve the name of tumors and which should be classified 
as such. 

Microscopically, lipoma is seen to be made up of adipose tissue 
containing fat-cells similar to those seen in the subcutaneous tissue, 



BENIGN TUMORS. 761 

but somewhat larger. It is usually developed from adipose tissue, 
but it also grows where 110 fat is found normally, as in the sub- 
mucous layer of the intestine. When there is a large amount of 
fibrous tissue in the new growth the tumor is much firmer, and it 
is known as fibrolipoma. Another variety is known as myxolipoma 
where there is a combination of the two allied tissues. In some 
cases the blood-vessels are very numerous, and a form of erectile 
tissue may be developed. Birch-Hirschfeld describes such forms 
of cavernous lipoma in the subcutaneous tissue of the arms of old 
persons. Combinations may occur also with sarcoma and car- 
cinoma. 

The typical circumscribed lipoma is found in the subcutaneous 
cellular tissue, and it appears as a lobulated soft tumor lying beneath 
the skin. It is more or less movable, and the lobulated shape may 
readily be determined by picking up the margin of the tumor 
between the thumb and finger. It grows slowly, but sometimes 
reaches enormous size, and then assumes the shape of a pendulous 
tumor (Fig. 118). The skin on such tumors is coarse and hyper- 

trophied, and sometimes 
is cedematous. When 
these huge growths are 
allowed to remain unop- 
erated, the most depend- 
ent portion of the skin 
eventually breaks down, 
and there forms a deep, 
well-defined ulcer, which 
extends through the skin, 
but which does not in- 
volve the tumor. Hemor- 
rhage often occurs under 
these circumstances, and 
the patient is finally driv- 

Fig. 118. — Lipoma of Thigh : on the left, skin ulcerated. 

en to seek surgical relief. 
The diffuse Upo7na occurs in the neck, and it gives to the patient 
a peculiar and grotesque appearance (Fig. 119). It was first de- 
scribed by Brodie, and later by McCormack, Hutchinson, and 
others. It is called u fat-neck " {Fetthals) by Madelung. The 
growth begins usually as a tumor situated over the mastoid pro- 
cess and behind the ears. It may exist on one or both sides of 
the neck. Finally, it covers the back of the neck, being divided 
into symmetrical halves by a depression on the median line. It is 




762 



SURGICAL PATHOLOGY AND THERAPEUTICS. 



sharply defined above at the superior curved line of the occipital 
bone, and it eventually grows around the neck, forming large folds 
at the side and the appearance of a" double chin ' ' in front. In 
one of Madelung's cases a large lobe extended downward over the 

clavicle. The tumor-growth spreads 
downward and below the muscular 
fibres in some cases, and even between 
the larynx and the pharynx. 

Diffuse lipoma appears usually in in- 
dividuals between thirty-five and forty- 
five years of age, and chiefly in men. 
Many of the patients are addicted to 
the use of alcohol, but in no case is 
general obesity described. The single 
case seen by the writer corresponded 
very accurately with the descriptions 
and portraits given by other writers. 
The patient was a middle-aged man 
^^m an d a heavy drinker. The tumor was 

removed at several operations, and, 
owing to the fact that there was no 
well-defined boundary to the growth, 
the dissection was difficult. In no case 
has there been any return of the growth 
after removal. Other forms of diffuse 
lipoma occur congenitally. The writer 
has on several occasions removed such 
diffused accumulations of fat from the cheeks of infants and young 
children. 

The situation of circumscribed lipomata has been carefully 
studied by Grosch, who finds that they are most frequently situ- 
ated on the neck and the shoulders and on the posterior surface of 
the trunk and the nates, consequently on those portions of the skin 
where the sudoriparous and sebaceous glands are most sparingly 
distributed. It is supposed that these glands rely largely upon 
the adipose tissue for the production of the excretion, and con- 
sequently unusual accumulations of adipose tissue are less likely 
to occur where they are found in large numbers. Multiple lipo- 
mata are also confined to the same localities, and they are often 
distributed symmetrically. Lipoma is rarely found on the head, 
but when so found it occurs more frequently on the face, particu- 
larly the forehead, than on the scalp. The palm of the hand and 




Fig. 



19. — Diffuse Lipoma of the 
Neck and Abdomen. 



BENIGN TUMORS. 763 

the sole of the foot are localities where it is seen less frequently 
than in any other part of the extremities. 

Lipoma is found also in the serous membranes and in the sub- 
mucous tissues of the mucous membranes. Enormous myxolipo- 
mata are often developed in the retroperitoneal space. Lipoma of 
the tongue has recently been observed by Rosenstirn. Lipoma is 
more frequently found in women than in men, and makes its 
appearance usually after middle life. Multiple lipomata are occa- 
sionally developed during childhood. Lipoma is a benign tumor, 
and it never returns after extirpation. It rarely disappears spon- 
taneously, even though the patient becomes greatly emaciated. 

8. Glioma. 

Gliomata are tumors that develop from the neuroglia or retic- 
ular substance which supports the fibres and cells of the central 
nervous system. Examined under the microscope, they are found 
to contain a network of extremely fine glistening fibres in which 
numerous oval nuclei are supported at some little distance from 
one another. A careful examination of these nuclei shows that 
they belong to cells which anastomose with one another by numer- 
ous delicate prolongations. These cells closely resemble the normal 
cells of the neuroglia, but they are usually larger, and some con- 
tain several nuclei. It is from the cells of the neuroglia that these 
growths develop, and not from the nerve-cells (Ziegler). The num- 
ber of cells in a glioma vary greatly. At times the cells predomi- 
nate, at other times the fibrous network. The vessels are occasion- 
ally very numerous. 

Glioma forms in the brain a tumor that is not easily distin- 
guished from the surrounding cerebral substance, with which it 
appears to be more or less continuous. Its presence is recognized 
chiefly by a swelling and by a diffusion of color. In the cord the 
glioma appears to form around the central canal, and it often 
spreads out over considerable portions of the spinal cord. It is 
usually of a bright-gray color, and is somewhat transparent, or it 
is a grayish-white or grayish-red, and even of a deep-red color 
when highly vascular. 

Gliomata are divided into hard, soft, and vascular forms. The 
hard form, or fibrog Ho >ma, which is found in the ependyma of the 
ventricles, is composed principally of a delicate fibrillated inter- 
cellular substance, and it is often associated with hydrocephalus. 
It may also occur elsewhere in the brain, and it is sometimes of 
almost cartilaginous hardness. It rarely attains great size. The 



764 SURGICAL PATHOLOGY AND THERAPEUTICS. 

soft glioma has a bluish-white color, such as is seen in hyaline 
cartilage, and it is sometimes hard to distinguish in alcoholic 
preparations from the surrounding cerebral substance, as it usu- 
ally has no well-defined outline. It often grows to the size of 
a child's head, being usually found in the white substance of the 
anterior and posterior lobes of the brain. It contains generally 
numerous large cells. The small-cell glioma is more vascular, 
and is particularly liable to hemorrhage. The gliomata may also 
undergo fatty degeneration and softening. 

Glioma is found in the retina in children. It contains both 
round and stellate cells. Eventually it may break through the 
sclerotic, and metastases may form in the orbital fat, in the diploe 
of the bones, and in the brain. In some cases metastatic deposits 
have been described in the liver, the kidneys, and the ovaries, but 
it is probable that these tumors belong in the group of sarcomata 
rather than to the gliomata. 

Neuroglioma ganglionare is a growth composed of neuroglia, 
of ganglion-cells, and of nerve-fibres, and it may be diffused or be 
circumscribed. A portion of the tumor undergoes a myxomatous 
change occasionally, and these growths are then known as myxo- 
glioma. In other cases there may be a combination with sarcoma 
(gliosarcoma). Glioma is rarely found in the cerebellum. When 
extensive degenerative changes occur in glioma it is often difficult 
to recognize the new formation, which is not suited to surgical 
interference, owing to its ill-defined outline. 

The subject of syringomyelia, that has been so much discussed of 
late in neurological literature, deserves consideration in connection 
with the general subject of glioma. The prevalent view is that in 
such cases, owing to a lack of developmental differentiation, there 
is a growth of quasi-embryonic tissue of the spinal cord specially 
involving the neighborhood of the posterior commissure and the 
posterior gray horns. Sometimes, also, there is an imperfect 
closure of the posterior cleft. Eventually, this gliomatous tissue 
is liable to break down, giving rise to the formation of cavities 
which are generally lined with pieces of membrane. This con- 
dition is commonly met with in the cervical portion of the cord, 
but occasionally is met with in other parts as well. It is some- 
times associated with spina bifida and sometimes with hydro- 
cephalus. 

The clinical symptoms which are most characteristic are a loss 
of the sense of pain and of temperature in certain well-defined 
areas, associated with a relative preservation of the sense of touch. 



BENIGN TUMORS. 765 

There is also a high degree of muscular atrophy, which usually 
occupies a smaller area than the sensory disorders. The disease is 
progressive and is not amenable to surgical treatment. 

9. Chondroma. 

Enchondroma, or chondroma, is a tumor which consists of 
cartilage. It occurs principally where cartilage is found nor- 
mally — that is, on the bones and in the cartilage of the respira- 
tory organs — but it mav also be found where there is no car- 
tila°:e. 

Virchow divided the chondromata into two forms: those which 
grow from cartilage, or the ecchondromata, and those which grow 
independently of cartilage, or the enchondromata. The former 
class is, however, a small one, the great majority of cartilaginous 
tumors belonoduor to the class of enchondromata. 

Enchondroma varies greatly in size. It may appear as a small 
round tumor or as a large lobulated growth (Fig. 120). It consists 
of either hyaline cartilage or of fibro-cartilage. The tumor may 
be in a state of mucous softening or be partially ossified. It may 
also be composed of osteoid tissue, such as is found in the ossify- 
ing callus between the bone and the periosteum, and it is then 
known as osteoid chondroma (Virchow). 

The tumor consists not only of cartilage, but also of connective 
tissue, which, however, is usually small in quantity. It separates 
the cartilage into numerous lobules. At times the fibrous tissue 
may preponderate to such an extent that very little cartilage is 
seen. The cells vary greatly in size, in form, and in numbers in 
different tumors and even in the same tumor. At times they are 
so numerous as to crowd against one another and leave little inter- 
cellular substance. They may be exceedingly few in number in 
other growths. They are often quite large, and contain one or 
more nuclei and a well-marked capsule. In other cases the capsule 
is wanting (Fig. 121). In some forms the cells are stellate with 
anastomosing prolongations: in these tumors the tissue is usually 
soft, and it has the appearance of myxoma. The intercellular 
substance is either hyaline or fibrous. Chondroma may be com- 
bined w T ith sarcoma. 

Cartilaginous tumors may undergo a mucous softening so far 
as the intercellular substance is concerned, and the cells in this 
case undergo fatty degeneration: these changes lead to the forma- 
tion of cysts. These tumors may also undergo calcification or 
ossification. At times chondroma may be highly vascular. Chon- 



766 SURGICAL PATHOLOGY AND THERAPEUTICS. 

droma occurs most frequently during youth, at a time when the 





Fig. 120. — Enchondroma of the Tibia, just below knee-joint (female; duration five years). 










-■•;;-.: v,--*,^ :••: v.- 



X 



*t *'- 









Fig. 121. — Hyaline Enchondroma (oc. 3, obj. D., and oc. 3, obj. A. ; hematoxylin staining). 

bones are developing: there is probably some connection between 
the formation of these tumors and irregularities in the development 



BENIGN TUMORS. 



767 



of bones. According to Birch-Hirschfeld, trauma appears to exert 

a decided influence upon the origin of this form of tumor. En- 

chondroma is often found on the 

long bones, and particularly upon 

the phalanges of the hand or upon 

the metatarsal bones (Fig. 122). 

It is observed 011 the larger long 

bones, on the scapula, on the 

bones of the cranium, on the 

jaws, and on the ribs. It is 

found also in the testicle, the 

parotid gland, the mammary 

and submaxillary glands, and 

the lungs. 

Virchow has given the name of ecchondrosis to those cartilag- 
inous tumors that grow directly from cartilage. Small cartilag- 
inous tumors are found in the thyroid cartilage and in the rings 
of the trachea, and also in the epiphyseal lines and in articular 
cartilage. They are found also on the costal cartilages, on the 
synchondroses, and on the intervertebral cartilages. Those that 
grow from the articular cartilage are often separated from their 



Fig 




Enchondroma of the Thumb. 




Fig. 123.— Mixed Cartilaginous Tumor of the Parotid Gland. 



base and wander about within the joint. These tumors are known 
as "loose cartilages" or "joint mice." They may spring also 



768 



SURGICAL PATHOLOGY AND THERAPEUTICS. 



from the synovial membrane or from the periosteum. They 
give rise to considerable irritation and effusion in the joint, 
but they may eventually become anchored in some pouch of 
the articular capsule. If a spontaneous cure does not occur 
in this way and they continue to give trouble, they should be 
excised. 

One of the most frequent of the fibro-cartilaginous tumors is 
the u mixed cartilaginous " tumor of Paget, which grows in the in- 
terstitial tissues of the parotid gland. In these tumors are seen 
numerous cylindrical masses of epithelial cells which are of gland- 
ular origin. These tumors are of slow growth and are nodular, 
and they can easily be separated from the tissue of the parotid 
gland. If allowed to grow, they may eventually attain an enor- 
mous size (Fig. 123). 

The hyaline enchondroma is also of slow growth, but it may at 

times assume immense propor- 
tions, as shown in the scapula 
of the patient whose portrait is 
here given (Fig. 124). 

The osteoid chondroma has a 
fibrous appearance. It develops 
from the periosteum, and it may 
form a spindle-shaped growth 
of considerable size in the long 
bones. These tumors are often 
sarcomatous, and Billroth pre- 
fers to classify them with the 
periosteal sarcomata. 

Chondroma is a benign 
growth, but in the rapidly-grow- 
ing forms the cell-growth is 
abundant, and the transition 
from chondroma to sarcoma not 
Fig. 124-Hyaline Enchondroma of the Scapula, infrequently occurs in portions 

of the tumor. 
Metastatic deposits of chondroma are to be distinguished from 
multiple chondromata, which are occasionally seen. Schuh re- 
ports the case of a girl, twelve years of age, who had such tumors 
on all the bones except those of the head and the spine. Chon- 
dromata show a tendency to break into the blood-vessels and the 
lymphatics, and portions of the growth are transmitted by em- 
bolism to distant organs, particularly the lungs. 




BENIGN TUMORS. 7 6 9 

10. Osteoma. 

Osteoma signifies a tumor composed of bony tissue. There are, 
however, several forms of bony growth which should not be re- 
garded as tumors. Such are the osteophytes, which form as the 
result of an inflammation of the periosteum; the diffuse enlarge- 
ments of bones, such as have already been studied; and the ossi- 
fication of tendons and muscles. An osteoma may grow upon the 
surface of the bone, and it is then called an "exostosis;" or it 
may grow in the interior of the bone as a firm bony nodule, and it 
is called an " enostosis. " It may also grow quite independently of 
bone, and it is this variety which Virchow regards as heterologous. 

Osteomata are placed in two different classes, according to the 
character of the bony substance of 
which they are composed. There are 
the hard or eburnated osteoma and 
the spongy osteoma. 

The most characteristic variety of 
osteoma dicrum is the ivory exostosis 
which occurs in the bones of the skull 
and the face (Fig. 125). It consists 
of a thick osseous tissue which is 
arranged in the form of concentric 
parallel lamellae: in the lamellae the 
bone-corpuscles are so arranged that 

their prolongations are directed to- Fig. 125.— Ivory Exostosis of the Orbit. 

ward the periphery of the tumor. 

The vessels are exceedingly few in number. The surface of the 
tumor is nodular and is covered by a thin layer of periosteum. 
There are also dense forms of osteoma that resemble more closely 
the structure of cortical bone. 

The ivory exostosis is found most frequently in the frontal bone, 
and it encroaches upon both the cavities of the cranium and the 
orbit, compressing the brain and protruding over both eyes (Paget). 
These tumors grow in the diploe or sinuses as isolated or as nar- 
rowly-attached masses. The size and situation of these growths 
make their removal often impossible, although in the simpler kinds 
operations have been performed with success. Their slight attach- 
ment is not infrequently destroyed, and necrosis follows and the 
tumors may be discharged spontaneously. Hutchinson describes 
such a growth lying loose in the orbit, which growth after its re- 
moval left a cavity nearly the size of the fist, over the upper and 
49 




77° SURGICAL PATHOLOGY AND THERAPEUTICS. 




Fig. 126. — Osteoma of the Lower Jaw. 



inner cavities of which the brain could be felt pulsating. The 
Warren Museum possesses the frontal bone of a patient from whom 
a portion of such a tumor was removed. The odontoma also 
consists of a dense ivory structure, and it may spring from the tooth 
or from the alveolar process. It is often associated with an ir- 
regularly-developed tooth. Hard os- 
seous tumors have also been found 
on the lower jaw (Fig. 126). 

Osteoma spongiostim contains in 
its interior more or less well-marked 
medullary tissue and spongy bone. 
These tumors are found growing 
from the epiphyseal lines of long 
bones, and are usually covered with 
a thin layer of cartilage. They are 
attached to the bone by a more or 
less well-defined pedicle. Some- 
times they are partially covered by 
a bursa filled with fluid, which gives them the appearance of being 
much larger than they really are. The writer has removed such 
tumors also from the scapula, and they may be found on other flat 
bones. Another form of spongy osteoma is the so-called ''subun- 
gual exostosis," which, according to Birch-Hirschfeld, is a perios- 
teal growth. It is found not infrequently growing beneath the 
nail of the great toe. This growth also has frequently a cartilag- 
inous surface. 

All these spongy osteomata grow to a certain size and then cease 
growing. With the exception of the last named they give little 
trouble. Occasionally, however, they reach an unusual size, and 
cases are reported in which the tumor grew to be as large as a 
man's head. 

Osteoma of bone develops either from the connective tissue of 
the periosteum or from cartilage or from the medullary tissue. 
Osteoma is also found entirely independent of bone. Such growths 
have been observed in the brain : they are supposed to develop 
from the neuroglia, and they have been regarded as an ossifying 
encephalitis (Birch-Hirschfeld). They also spring from the me- 
ninges. Bony tumors are found in the eye and in the lungs, and 
miliary bony tumors are also seen, though rarely, in the skin. 
Multiple osteomata are seen not only upon the bones of the skull 
and other flat bones, but also upon the long bones. 

In regard to the etiology of osteoma, it is supposed by many 



BENIGN TUMORS. 771 

that there is an hereditary predisposition, particularly in cases of 
multiple osteoma. These tumors appear occasionally after injuries. 
Syphilis and gout are also supposed at times to exert an influence 
favorable to the development of bony growths. The prognosis of 
osteoma is favorable, as it is strictly a benign tumor. 

11. Neuroma. 

"Neuroma" is a term originally applied to a tumor supposed 
to consist of nerve-tissue. Many of these tumors prove on micro- 
scopical examination to be composed of nerve-tissue to a limited 
extent only, the bulk of the growth consisting of fibrous tissue. 
A new formation of nerve-tissue does, however, occur. The term 
neuroma fibrillare is used to indicate growths of nerve-fibres. 
Neuroma cellulare is a tumor consisting of new-formed ganglion- 
cells. When the tumor is composed of fibres which contain no 
myelin, it is spoken of as a "neuroma amyelinicum." When 
the fibres contain myelin, the growth is called "neuroma mye- 
lenicum." 

Neuroma cellulare is an exceedingly rare growth. One case is 
reported as existing in the ala of the nose of a man thirty-one 
years of age. It is more frequently found in the brain, usually in 
the lateral ventricle. A growth of ganglion-cells may be found 
in a teratoma of the ovary or the testicle, and also in congenital 
sacral tumors. 

Neuroma myelinicum occurs either as a circumscribed round or 
lobulated nodule, as a spindle-shaped tumor, or as a diffuse thick- 
ening of a nerve arranged in knots or in loops. It consists of a 
mass of firm, grayish-white tissue, composed of interlacing bun- 
dles of fibres, between which is a moderate amount of loose con- 
nective tissue poorly supplied with blood-vessels. A microscopic 
examination shows the myelin-fibres, which are stained black by 
hyperosmic acid. 

The amyelinic neuroma is a yellowish or a whitish -gray tumor 
of considerable firmness, having somewhat the appearance on 
section of a fibroma. Under the microscope the nerve-fibres with 
their nuclei can be made out by picking them gently apart (Wini- 
warter). 

Neuroma may occur either singly or as a multiple tumor, and 
it is accompanied by an increase in the connective tissue of the 
nerve, particularly of the outer (and less frequently of the inner) 
layers of the endoneurium, so that the bundles of nerve-fibres at 
the seat of the tumor are surrounded by a loose growth of connec- 



772 SURGICAL PATHOLOGY AND THERAPEUTICS. 

tive tissue. The perineurium may also be involved in this 
growth, but the epineurium is rarely affected. Such a tumor is 
therefore, strictly speaking, a neurofibroma. 

Multiple neuromata may be found existing at several points in 
a nerve-trunk, or they may be situated in the various branches of 
a nerve, or they may be indiscriminately distributed throughout 
the body. A single neuroma is more likely to be painful than the 
multiple form. The nervous disturbance depends, however, upon 
the attachment of the tumor to the nerve. If it is so situated that 
the nerve-fibres are compressed, whether the tumor be central or 
be peripheral there is more likely to be pain than when the fibres 
are spread out tape-like over the tumor. Multiple neuromata may 
be seen as a string of nodules following the course of a nerve- 
trunk, or as nodular growths spread out beneath the skin in 
various directions. They are usually movable. If adherent to 
the surrounding structures, there is a possibility that the growth 
may be sarcomatous — a combination that not infrequently occurs. 

Many neuromata are congenital or they appear during the early 
years of life. They are not infrequently found in persons of 
defective mental development. Heredity appears to exert an 
important influence, as multiple neuroma is often seen in various 
members of a family. Acquired neuromata appear between the 
ages of twenty and forty years. 

The so-called "malignant neuroma'''' is usually neurosarcoma 
or neuromyxoma. There is in these growths a new formation of 
nerve-fibre, but their principal feature is the malignant element, 
and these tumors may be the origin of metastatic deposits. The 
neuroma amyelinicum may suddenly change its benign nature and 
become converted into a malignant growth. 

Plexiform neuroma consists of a convolution of numerous 
bundles of fibres which have nodular swellings at various points, 
and which are intertwined in a tangled mass. They are held 
together by a loose connective tissue that lies in a fold of skin, 
which is hypertrophied and pigmented and covered with a thick, 
coarse hair. The tumor is congenital, and it is usually situated 
on the scalp, on the neck, or on the cheek. There is a thickening 
also of the connective-tissue structures of the skin, particularly 
those surrounding the vessels and the hair-follicles, such as has 
already been described in the case of multiple fibromata. The 
growth is regarded by many as a local congenital elephantiasis of 
the nerves. The neuroma found in the ends of divided nerves is 
the form of tumor with which the surgeon is most familiar. Such 



BENIGN TUMORS. 



773 







growths occur both in the peripheral and in the central end of a 
nerve which has been divided in continuity, and are often observed 
by the surgeon who lays bare the nerve for the 
purpose of uniting the severed ends. But the 
commonest form is that found in amputation- 
stumps, and it is the cause often of intense neur- 
algic pain (Fig. 127). It is evident that these 
growths are the result of an abortive attempt at 
repair of the injured nerve, and there is found here 
virtually the same process going on which has 
already been described in the section devoted to 
the repair of nerve-fibres. There is a growth of 
the nerve-cylinders, which are imbedded in a mass 
of fibrous tissue forming around the end of the 
nerve. Such tumors appear to form in the nerves 
of the stump of an amputated arm more fre- 
quently than elsewhere. 

The excision of a portion of the affected nerve- 
trunk usually results in a cure of the neuralgia. 
Occasionally the pain returns. Winiwarter in- 
vented an ingenious operation to meet the dif- 
ficulties presenting in an obstinate case. On one 
occasion he divided the brachial plexus above the 
clavicle and united the central stumps of the 
nerves in pairs, so that the peripheral portion 
should completely be isolated. This operation was 
successful. 

A form of tumor which is generally supposed to be a neuroma 
is the so-called u painful subcittaneous tumor" described by Paget. 
It is usually found in the extremities, especially the lower. Very 
rarely it occurs on the trunk and the face. It is seen more fre- 
quently in women than in men. It consists of a small tumor situ- 
ated just beneath the skin. Occasionally amyelinic nerve-fibres 
are found in it, but it may consist also of a loose or a dense con- 
nective tissue or of fibro-cartilage. Some of these little tumors 
proved to be leiomyoma and others angioma, and still others 
adenoma of the sweat-glands. Their structure is therefore not cha- 
racteristic of any particular variety of tumor, and the pain is prob- 
ably due to the involvement of some sensitive nerve-fibre in the 
growth. 



Fig. 

ma from an Am- 
putation-s tump 
(Sp. 1 154, War- 
ren Museum). 



774 SURGICAL PATHOLOGY AND THERAPEUTICS. 



12. Myoma. 

Tumors composed of muscular fibre are divided into two classes. 
To the first class belongs the leiomyma, or a tumor made up of un- 
striped muscular fibre; to the second belongs rhabdomyoma, a much 
rarer form, which is composed of cells closely resembling striped 
muscular fibre. Virchow named these two forms "myoma lsevi- 
cellulare ' ' and * ' myoma striocellulare, ' ' respectively. 

Leiomyoma is found most frequently in the uterus, and occasion- 
ally also in the muscular layer of the intestine and the urinary 
organs. It is also seen, though rarely, in the ovary; it is likewise 
found in rare instances in the skin and in the subcutaneous cellu- 
lar tissue. The muscular cells are arranged in bundles which run 
in straight or in wavy masses more or less parallel with one another. 
Many bundles, however, are found running at right angles or more 
or less obliquely to the others. Between these bundles there exists 
a more or less vascular connective tissue. When properly stained 
the long staff-shaped nuclei are brought out quite distinctly, and 
the cells are then seen to exist in great numbers (Fig. 128). The 




Fig. 128. — Myoma of the Uterus. 



cells may be isolated by picking them apart in the fresh state, by 
allowing them to remain for twenty-four hours in a 20 per cent, so- 
lution of nitric acid, or by placing them for twenty or thirty min- 
utes in potash. In the small and succulent myomata of the uterus 



BENIGN TUMORS. 775 

the tissue is made up almost entirely of muscular fibre. In the 
large tumors a considerable portion of the substance of the growth 
consists of a firm, dense fibrous tissue. These tumors are called 
" fibroinyomata. " In some cases the connective-tissue growth is 
soft and areolar, and such tumors are much less dense. Myoma is 
not usually a vascular tumor, but in some cases the development 
of blood-vessels is quite marked. In other specimens larger lymph- 
spaces are found between the bundles of fibres,, and at times there 
are seen cysts of considerable size, due to a dilatation of these spaces. 
Nerves are occasionally also seen in these growths. The fibrous 
portions of these tumors appear as a glistening white, almost ten- 
dinous, tissue; the muscular portion, as a reddish-white or a gray 
structure. 

The growth of these tumors in the uterus is exceedingly slow, 
but they may eventually assume a greater size than that of any 
other known tumor. They may be single or multiple. They may 
grow on the outer wall of the uterus, and in that case they project 
into the peritoneal cavity. Such tumors are known as subserous 
myomata. When the growth originates in the middle layers of the 
uterine wall the tumor is called an "interstitial myoma." Those 
growths projecting into the cavity of the uterus are known as " sub- 
mucous myomata." All these forms may occur in the cervix as 
well as in the body of the uterus. 

Uterine myoma frequently undergoes considerable changes in 
volume, increasing materially in size at the period of menstruation. 
Many of the changes are produced by the increased flow of blood 
or by a dilatation of the lymph-spaces. A marked decrease in its 
size may be produced by contraction of the muscular fibre, partic- 
ularly when it is subjected to the long-continued action of ergot. 
Uterine myomata may undergo softening. This change occurs in 
large growths, and it is due to disturbance of circulation. Fatty 
degeneration and cysts are seen under such conditions. Calcification 
occurs in old myomata, particularly in those attached by a narrow 
pedicle. The change takes place in the connective tissue, the 
muscular fibres undergoing at the same time fatty degeneration. 
In some cases osteoid tissue is found, and some of these tumors 
have a bone-like hardness. 

Many cases of leiomyoma have been reported growing in the 
stomach and in the intestinal canal. It is only in exceedingly rare 
instances that they attain a large size. The growth is found in the 
ovary, and it may produce a large solid ovarian tumor. Such a 
tumor was recently removed by the writer from a woman about 



yy6 SURGICAL PATHOLOGY AND THERAPEUTICS. 

forty-five years of age, and it had a large amount of unstriped mus- 
cular fibre. It was about the size of a child's head and weighed 
eight and a half pounds. 

Many of the cases of enlarged prostate are due to a new forma- 
tion of muscular fibre. In some cases there is general hypertrophy 
of all the constituent parts of the gland ; in other cases the glandu- 
lar structures appear to form the greater part of the growth. The 
principal seat of the muscular growth is in the upper and posterior 
portions of the gland in the condition known as hypertrophy of the 
middle lobe (Birch-Hirschfeld). 

Myoma of the skin is always composed of unstriped muscular 
fibres. The development of the new muscular cells takes place 
either from the muscular walls of the blood-vessels, from the erec- 
tores pilorum, or from those muscular structures seen in the sub- 
cutaneous tissue in the scrotum, the labia, the nipples, or the 
face. 

Pure myoma of the skin or of the subcutaneous tissue may 
either be solitary or be multiple, and it usually grows to the size of 
a cherry. It is moderately soft, and it appears on section as a red- 
dish-white tissue resembling either a sarcoma or a fibroma accord- 
ing to its density. It may be found in the scrotum, the labia, or 
the nipple, or in almost any region of the body. When situated 
in the skin it appears as a yellowish-red or a dark-red tumor. It is 
found more frequently in young people, and is probably in most 
cases congenital. Many of the cases of true keloid are undoubtedly 
partly muscular in structure; hence they should be regarded as 
fibromyomata. Combinations of myoma with sarcoma rarely occur. 
In angioma the walls of the blood-vessels or the vascular spaces are 
composed of muscular fibre, which frequently constitutes the prin- 
cipal portion of the tumor. Such a tumor should, therefore, be 
called " angiomyoma." Diffuse forms of myoma are seen in those 
cases of hypertrophy of the skin of the scrotum partaking of the 
character of elephantiasis. 

Rhabdomyoma, or a tumor consisting of striped muscular fibre, 
is a rare growth as an independent tumor. It is found more fre- 
quently in combination with sarcoma. Bands of spindle-cells with 
striae are then seen. A pure rhabdomyoma contains bands of these 
cells that are marked more or less clearly with striations. In addi- 
tion to long spindle-shaped fibres there are seen round or club- 
shaped cells with or without prolongations (Ziegler). Rhabdo- 
myoma is found in the testicle, in the heart, and in the muscular 
system. Myosarcoma is found in the kidney and in the testicle. It 



BENIGN TUMORS. 777 

has been observed also in the stroma of an ovarian cyst and in cer- 
tain forms of teratoma. 

13. Angioma. 

The name angioma is given to tumors the main portion of which 
is composed of new-formed blood-vessels. There are two princi- 
pal varieties of angioma — the plexiform angioma or naevus and 
the cavernous angioma. In the former there is presented a tumor 
composed of vessels which have preserved their character. In the 
latter there are no distinct vessels, but there is a spongy tissue 
composed of a stroma containing spaces lined with endothelium 
and resembling the erectile tissue. 

Plexiform angioma, teleangiectasis, or naevus is of two kinds. 
The superficial forms of naevus, or "mother's marks," appear 
either as bright-red or claret-colored marks upon the skin or as 
slightly raised portions of the skin also stained a deep red. In the 
former the skin appears to be unaltered as to texture. These dis- 
col orations appear to be due to an enlargement of the capillary 
vessels in the papillae from which spring other vessels. The out- 
line of these spots is either well defined or there are a number of 
minute prolongations running in varying directions. Minute 
blemishes of this kind, which are not uncommon on the nose or 
the cheeks of young children, are popularly known as "spider 
cancers ' ' (naevus aranaeus), and the larger spots are known as 
"port-wine marks." 

Occasionally the skin appears to be hypertrophied and coarse- 
grained, which is due to hypertrophy of the papillae. These spots 
appear at or soon after birth, and they may increase considerably 
in size, but usually they do not materially change. In the cavern- 
ous form the vascular structure is more developed. Here one finds 
coils of capillary vessels or arterioles which are grouped together 
in lobules, and which have apparently taken their origin in the 
subcutaneous adipose tissue, and gradually worked their way up 
through the channels of the skin to the surface, where they make 
their appearance soon after birth. They are raised somewhat 
above the surface of the skin, and have a bright-red color, with a 
slightly irregular border. The part beneath the skin is much 
more extensive than that which appears upon the surface. When 
pressed upon firmly the vessels are emptied of their blood and the 
tumor disappears, but it is soon again filled by faintly-pulsating 
waves. 

In some of these growths the muscular cells are very numerous, 



77 8 



SURGICAL PATHOLOGY AND THERAPEUTICS. 



and the vessels are then usually narrow. These growths are 
known as "angiomyomata." Sometimes the walls of the vessels 
are very thin, and they here and there present varicosities. Such 
conditions are found in angioma of the brain and in a telangiec- 
tatic condition of certain tumors. Plexiform angiomata, or naevi, 
are found principally upon the head, the neck, and the chest. 
They are rarely found on the mucous membrane or on the serous 
surfaces of the liver, the spleen, or the kidney. They are often 
multiple. 

The more vascular forms of nsevus sometimes become very for- 
midable growths, and they 
are difficult to arrest in their 
progress, covering as they do 
large surfaces and ultimately 
causing death from hemor- 
rhage (Fig. 129). Fortunately, 
this class is rare, and the little 
tumors if excised do not re- 
turn. The smallest naevi may 
be cured by puncture with a 
hot needle or with the fine 
point of a Paquelin cautery. 
The port-wine marks, which 
are usually too extensive 
for excision, are not affect- 
ed by any other treatment. 
They do not, however, tend 
to grow beyond a certain 
point. The cavernous an- 
gioma is composed of tissue 
like that of the corpora cavernosa. 

It is probable that the pure form of this disease develops from 
the venous capillaries by a process of budding of solid masses of 
protoplasm, which subsequently became hollowed out and con- 
verted into cavernous tissue. It is supposed that in some cases the 
growth develops from the capillaries of the part, which become 
dilated and fused together. In other cases it is possible that com- 
munication takes place between previously-formed spaces (lymph- 
spaces) and the veins. The stroma consists of a connective-tissue 
trabecular, which surround spaces whose walls are lined with en- 
dothelium, and in which spaces the blood is largely venous (Fig. 
130). It is only in rare cases that these tumors communicate with 




Fig. 129. — Angioma of the Lip and the Neck. 



BENIGN TUMORS. 



779 



a large arterial branch. Nerves are sometimes found in these 
tumors, and the muscular cells are often seen in large numbers. 

The tumor appears as a raised and lobulated mass occupying 
the skin or the subcutaneous tissue, with a more or less well-defined 
outline. The color is either that of the skin or of a deep-blue 
shade. When connected with the arterial system the color is a 
bright red. 

Naevi are found not only on the surface of the body, but more 
rarely also in the muscles, the glands, and the bones. Their com- 












hi 



Fig. no, 



-Cavernous Angioma. 



monest seat in the internal organs is the liver, but they are seen 
also in some instances in the uterus, in the intestine, and in the 
bladder. 

The cavernous angioma is rarely congenital, but it appears 
rather late in life in the internal organs, and during the first half 
of life it appears in the skin and the subcutaneous tissue. Many 
of these tumors are exquisitely sensitive. They grow slowly, but 
they may become quite formidable and dangerous, owing to their 
size and to their liability to hemorrhage. 

The accompanying drawing shows such a growth upon the 
scalp of a young man (Fig. 131). It was removed by an almost 
bloodless operation with the Paquelin knife. There were in the 
neighborhood several smaller wart-like angiomata, which, as they 



780 



SURGICAL PATHOLOGY AND THERAPEUTICS. 




Fig. 131. — Angioma of the Scalp. 



had not increased in size, were not treated. In cases where the 
growth is too deep for excision the cautery may be used or a deep 

ligature may be made to encircle 
the mass. 

Angioma venosum, or varix, 
is a tumor composed of dilated 
veins, such as are seen in hemor- 
rhoidal tumors. They are found 
also in the face and the neck and 
in the scrotum and the labia. 
Some of these tumors are simply 
dilated veins; others are probably 
formed by a new development of 
venous blood-vessels, particularly 
those in the face and the neck. 

Aneurisma racemosum, or cir- 
soid aneurism, resembles the va- 
rix closely, but it is composed of 
dilated arteries instead of veins 
(varix arterialis). This dilatation 
is found in arteries of medium size, and principally upon the head, 
on the upper extremity, and on the back. Most of these tumors 
are composed of arteries of new formation, and are therefore genu- 
ine tumors. The growth of new arteries occurs very much in the 
same way that new vessels form in the healing of wounds. These 
growths are sometimes most formidable affairs. 

Such a case occurred in the hospital service of trie late Dr. G. H. Gay. 
The tumor, which covered the median portion of the scalp, had a prolonga- 
tion that divided on the bridge of the nose and ran obliquely across each 
cheek. Near the vertex the mass appeared to consist of one or two large 
chambers, and radiating from the main body of the tumor were large arteries 
occupying the seat of the temporal, occipital, and facial vessels. The writer 
was called to the hospital to see the patient, and he found him with an 
abdominal tourniquet applied to a rupture on the top of the tumor. On 
removing this compress a perfect geyser of blood spurted up to the height of 
a foot into the air. This discharge emptied the sac, which was seized and 
ligatured. The writer ligatured several of the large arteries. A few weeks 
later Dr. Gay transfixed the growth with long needles and over them passed 
figure-of-8 ligatures. The mass sloughed away and left a healthy granulating 
surface which healed. About fifteen years later the writer removed an epi- 
thelioma from the nose of this patient, on whom there was hardly a trace of 
the old scar. 



A tumor of precisely the same description is given in Ziegler's 



BENIGN TUMORS. 781 

Pathological Anatomy. In the case reported the vessels seem to 
have fused together, forming in the tumor several large chambers. 



14. Lymphangioma. 

Lymphangioma is a tumor which bears the same relation to the 
lymphatics that angioma does to the blood-vessels. It consists of 
a connective-tissue network the meshes of which contain lymph- 
spaces lined with an endothelium. In addition to the connective- 
tissue stroma there exists often fibrous tissue and adipose tissue, 
and occasionally numerous blood-vessels. The following de- 
scribed three varieties are recognized: The lymphangioma sim- 
plex, or teleangiectasia lymphatica, which consists of a congeries 
of dilated lymphatic vessels that are in part a new formation and 
in part a dilatation of pre-existing vessels : according to Wegner, 
this variety is due to an obstruction in the lymphatic circulation, 
and it is analogous to the venous varix; the lymphangioma caver- 
nosum, which consists of a stroma that surrounds cavities formed 
by the fusion of pre-existing and new-formed lymphatic vessels 
and of lymph-spaces filled with lymph (Winiwarter); the lymph- 
angioma cystoides, which consists of a cyst, simple or compound, 
filled with lymph, supposed to be formed by the fusion of the 
lymph-spaces of a cavernous lymphangioma. 

Lymphangioma is a rare form of tumor. It is frequently con- 
genital, but it may also be an acquired growth. It is found in the 
skin and the subcutaneous tissue, and also in the tongue, the 
gums, and the lips, as well as in the scrotum and the labium. 
The writer has seen a well-marked cavernous angioma in the skin 
of the back of an adult and in the axilla of a child. 

The simple lymphangioma is often accompanied by an oedema 
and thickening of the skin, which condition has been called 
"elephantiasis" or "pachydermia lymphangiectatica." Such 
conditions are found in the scrotum, the penis, the prepuce, the 
clitoris, the labia majora, etc. It is found also in the tongue in 
macroglossia, and on the conjunctiva. It often forms a part of 
the congenital diffuse hypertrophies of the lips and the cheeks. 
According to Virchow, in tropical countries lymphangiectasia may 
occur in bunches of lymph-glands. This form of lymphangioma 
may be circumscribed or be diffuse. Occasionally perforation may- 
take place at some point, and a lymph -fistula is developed from 
which a clear serum exudes drop by drop. 

The cavernous lymphangioma consists of a number of large 



782 



SURGICAL PATHOLOGY AND THERAPEUTICS. 






Fig. 132. — Lymphangioma. 



lymph-spaces communicating more or less perfectly with one 
another and containing a clear or a milky fluid. It appears as a 
soft, more or less fluctuating tumor on the face, the trunk, or the 

extremities, and it is easily 
mistaken for a lipoma or an 
angioma, and even after op- 
eration it is often difficult to 
decide as to the exact nature 
of the growth. The accom- 
panying drawing is a por- 
trait of the cavernous type 
(Fig. 132). One of the 
lobes was aspirated and the 
child died of septicaemia. 

Cystic lymphangioma, 
which is usually found in 
the neck, is one form of 
hydrocele of the neck. It 
should, however, be re- 
membered that a certain 
number of these cases of 
hydrocele are branchial cysts, as has already been seen. The cyst 
is lined with endothelium, and it may contain either a clear or a 
bloody fluid. Some of these cysts run in between the muscles. 
Winiwarter reports such a complicated cyst associated with mic- 
roglossia. 

These cysts are situated in the upper part of the neck, and they 
may send prolongations as far as the mediastinum. In one case 
which came under the writer's care there was a swelling beneath 
the angle of the jaw, on opening which swelling a large quantity 
of clear serum escaped. The ramifications of the cyst were so 
extensive that it was impossible to follow them. The patient was 
an adult. Most of these cases of hydrocele, however, are con- 
genital, but they grow slowly. Congenital cystic lymphangioma 
is also found between the skin and the sacrum. 

The operative treatment of these tumors at the present time is 
not nearly so dangerous a proceeding as formerly, but the direct 
communication with the lymphatic system renders such cases 
liable to general septic infection if strict asepsis is not observed. 
In the cases of hypertrophy wedge-shaped masses should be 
excised to relieve the deformity. Many of the well-defined forms 
of lymphangioma can be extirpated: when this is not possible free 



BENIGN TUMORS. 783 

incision should be made, and the cavities should be stuffed with an 
aseptic or iodoform gauze. 

15. PSAMMOMA. 

Psammoma is a growth usually found on the membranes of the 
brain, and it contains calcareous concretions. Particles of sand 
are found in the pineal gland, on the choroid plexus, in the Pac- 
chionian bodies, and in small bodies on the dura mater. Tumors 
containing sand are found occasionally also in the lymphatic 
glands, the thymus gland, and on the capsule of the testicle. 
They may also be found in sarcomatous and in carcinomatous 
growths. 

The particles of sand are scattered over the tumor, and they are 
found lying either in a connective-tissue stroma which has under- 
gone a hyaline degeneration, or are surrounded by concentric layers 
of cells, which, according to many observers, are endothelial in 
character. The origin of these concretions, according to Birch- 
Hirschfeld and others, is due to a retrograde change in a growth 
of bud-like sprouts from the walls of the blood-vessels. The only 
specimen examined by the writer was a tumor the size of a 
pigeon's egg which was removed from the dura mater. It was 
white and had a fibrous appearance. Microscopically, it consisted 
of numerous concretions surrounded by cells apparently of an 
endothelial nature. There were numerous fibrous septa which 
supported this rich cell-structure. The fibrous forms of psammoma 
are benign growths, but k is well to remember that these concre- 
tions may also be found in malignant tumors. 



APPENDIX 



I. SCIENTIFIC AIDS TO SURGICAL DIAGNOSIS. 

IT is the purpose in this section to consider the methods which 
have been developed whereby the surgeon is enabled, by the exam- 
ination of the blood and the various excretions and secretions of 
the body and the other methods of precision, to have the most 
exact data possible in order for him to arrive at his diagnosis and 
prognosis. It is not intended to speak in detail of the methods to 
be employed in making the examinations, but to consider so far as 
possible only those processes which will probably throw light upon 
surgical conditions. The mass of literature upon the various lab- 
oratory methods and the routine experiments carried on in hos- 
pitals are most perplexing to the practitioner ; yet from this large 
amount of material some certain results have been obtained, and it 
is desired to set forth these so far as possible, leaving the problem- 
atical questions entirely aside. These latter may or may not find 
a place among the permanent aids to diagnosis ; but until they do, 
thev deserve no place in a text-book devoted to facts. 

The student who wishes to do his own laboratory work is 
referred for the details of the methods which are here mentioned 
to Mallory and Wright's Pathological Technique or to Simon's 
Clinical Diagnosis ; and he is assured that patience and persever- 
ance will make him sufficiently proficient in making practically 
all of the important tests which will yield valuable clinical evi- 
dence for the establishment of accurate diagnosis and prognosis. 

It is part of every surgeon's duty, in so far as he is called upon 
to be a diagnostician, as well as an operator, to know what labora- 
tory methods can be expected to yield him positive results, and to 
be able to call upon his assistant or an expert to make the report 
upon the point to be elucidated. He should not send a specimen 
of blood or urine, or any secretion or excretion, simply on the 
chance that it may yield some knowledge, but must have a clear 
idea of the point upon which he wants negative or confirmatory 
information. 

No attempt is here made to consider symptoms which, though 
closely connected with the subject under consideration, really 
belong to the clinical history of the case. As an example of 
what is meant, would be the fact that in hemorrhage coming from 
the bladder, if micturition is painless, it is strongly indicative of 
tumor of the bladder ; or if from the kidney and intermittent, it 
strongly points to a new growth. These are clinical observa- 
tions which are important in the case, but have nothing to do with 

50 785 



786 SURGICAL PATHOLOGY AND THERAPEUTICS. 

laboratory observations for the determination of the seat of the 
hemorrhage. 

Blood-examination as an Aid to Surgical Diagnosis. — 

Although a great deal has been written of late years about the 
examination of the blood, but very little of it is applicable as an 
assistance to surgical diagnosis. Practically no surgical diseases 
present pathognomonic blood-conditions ; but in spite of this a 
good deal of light may be obtained which will be of great value 
in arriving at a correct diagnosis. 

As regards anemia : Many people are by no means absolutely 
deficient in hemoglobin, though they may be very pale. People 
may also have a very exaggerated idea of the amount of blood 
they have lost in hemorrhages from the bowels, stomach, uterus, 
nose, or elsewhere. In cases where there is doubt as to the 
patient's or friends' statements, the estimation of the hemoglobin 
will usually determine whether or not there is profound anemia 
resulting from these conditions. 

By far the greatest amount of information about surgical condi- 
tions is to be derived from the white blood-count showing absence 
or presence of a leukocytosis, and its amount if present. The 
normal number of white blood-corpuscles, or leukocytes, is about 
6000 to 7500 to the cubic millimeter. This is increased in all 
inflammatory conditions produced by the ordinary pyogenic cocci. 
The value of such a fact is at once clear, for inflammatory condi- 
tions are by far the most frequent with which the general surgeon 
has to deal. Next of importance for the surgeon to remember is 
that uncomplicated typhoid fever, tuberculosis, and malaria give 
rise to practically no increase in the number of leukocytes; hence 
in all those obscure cases where one of these diseases rather than 
an inflammatory condition could explain an obscure clinical his- 
tory, the probability would be made all the stronger by finding a 
practically normal leukocytosis. In the cases of both typhoid 
fever and malaria this probability can be made certainty by further 
blood-examination if in the former case the agglutination-reaction 
is demonstrated, or the presence of the. Plasmodium malarics in the 
latter. 

Intestinal obstruction, whether or not of malignant character, 
usually shows leukocytosis, which is especially apt to be marked 
in cases of cancerous obstruction. Therefore the blood-count can- 
not be resorted to in order to give differentiation between intestinal 
obstruction and intestinal paralysis, resulting from peritonitis, 
whether general or local. Further, in regard to the acute inflam- 
matory processes in the abdomen in very light cases, as, for exam- 
ple, catarrhal appendicitis and salpingitis, the leukocytosis is often 
small, while the same is true in the severe cases of fulminating 
appendicitis. So no one should make the mistake, in a case of 
appendicitis where symptoms all point to severe trouble, that the 
absence of all leukocytosis or the presence of only a small increase 
in the white count at all does away with the diagnosis established 
by the clinical symptoms ; it rather strengthens the diagnosis and 
may make the prognosis more unfavorable. 



SCIENTIFIC AIDS TO SURGICAL DIAGNOSIS. 787 

In cases where a diagnosis has been made of an inflammatory 
condition or of suppuration, bnt where it seems doubtful whether 
operative interference is necessary, repeated white blood-counts are 
of the greatest assistance, an increase in the number of leukocytes 
denoting an extension of the process and a diminution showing 
favorable progress toward absorption. Sudden increase in leuko- 
cytosis is often the first sign of pocketing of pus in or about a 
wound. This sometimes occurs even before a corresponding rise 
in the temperature ; or in other cases it will show that the rise of 
temperature which has been observed is due to extension of the 
inflammatory or suppurative process, and not to other general con- 
ditions which might explain the appearance of fever. 

Where a surgeon is removed from the facilities for making suit- 
able microscopic examinations, not having the necessary apparatus 
for making blood-counts and examination of fresh blood, it is well 
to remember that often a good many points may be obtained by an 
expert examination of the dried specimen of the blood. One who 
has done a great deal of blood- work is able from such a prepara- 
tion to give a very fair estimate of the amount of hemoglobin from 
the color of the corpuscles, and of the degree of leukocytosis from 
the proportion of whites that appear in the field. The presence 
of malarial parasites can also be determined ; while the variety of 
the leukocytic cells present will give more or less indication, as the 
case may be, of the actual condition of the patient. 

The cover-slips for such an examination should be carefully 
spread and sent by mail to the nearest expert on the blood. 
Although as much cannot be hoped for as from repeated examina- 
tions by an assistant at the bedside, yet such examination may 
help in the diagnosis of some doubtful and perplexing case. When 
such a specimen is sent it is especially important, as it is also 
desirable in all cases, to give the examiner as clear an idea as is 
possible of what is expected. For example, do the red corpuscles 
show marked loss of hemoglobin? Are there malarial parasites 
present ? Is there an apparent leukocytosis ? A differential count 
is not desired unless it should seem necessary. 

As has been stated in the first part of this section, the surgeon 
should know what he wants looked for and ask for it. Then, 
should anything of diagnostic value accidentally appear, the exam- 
iner is bound to add it in his report. 

In cases of doubtful cancer of the stomach the presence or 
absence of the so-called digestive leukocytosis will give a hint as 
to the functional activity of the stomach ; but as this activity is 
checked by so many non-malignant conditions it is at best but a 
hint. 

Of the chemical constituents of the blood but one deserves 
special notice from the standpoint of the surgeon. Sugar is a 
normal constituent of the blood. In certain conditions it is much 
increased above the normal ; chief of these is carcinoma. Tuber- 
culosis and syphilis, though showing an increase, are so far below 
the amount found in cancer that usually they do not cause confu- 
sion. It seems that this increase in the sugar in the blood proba- 



788 SURGICAL PATHOLOGY AND THERAPEUTICS. 

bly appears early and is not augmented by advancing cachexia. 
Should one wish for such an examination of the blood for the 
presence of excess of sugar, half an ounce of blood should be col- 
lected and be put in four or five ounces of strong alcohol. The 
time of taking the blood should be marked upon the label, and the 
mixture should be sent to the analyst so as to arrive within two or 
three hours from the time it was drawn. 

Bacteriological Examinations. — The varieties of bacteria 
found in the various inflammatory processes are often of great aid 
in both prognosis and diagnosis, and often determine questions 
arising as to the extent of an operation. The methods are simple 
by which this information is obtained ; and even where no direct 
knowledge is gained it is well for each surgeon, as far as possi- 
ble, to collect such statistics as he can in order that at some time 
a comparison with other similar work may lead to an advance in 
our clinical information. A very small outfit is needed to enable 
one to do all the necessary proceedings : cover-glasses on which 
smear-preparations can be made, a few test-tubes plugged with 
cotton and sterilized, and a few brass or copper wires on one end 
of which a little cotton has been rolled. These sterilized cotton 
swabs are used to collect pus or other fluids to be examined (see 
page 160). For obtaining joint, pleural, or pericardial fluid an 
ordinary hollow needle or small trocar, suitable for the occasion, 
and an ordinary glass syringe, having a short piece of rubber 
tubing which serves as a connection with the needle, are all the 
equipment necessary. This combination is easily sterilized by 
boiling. The size of the syringe can be graduated to the wants of 
the individual case ; if, however, one wishes to use a more elabor- 
ate form of syringe, he will find plenty in the market from which 
to select. 

For purposes of study of pathological bacteria by means of cult- 
ures, blood-serum is the easiest and best medium to employ, 
and except in very rare instances none other is needed. A few 
drops of the fluid withdrawn by the needle are put upon the sur- 
face of the blood-serum or the swab which has been dipped in the 
pus is drawn over the surface. In most instances the bacteria are 
so infrequent in the pathological material which it is desired to 
study, that discrete colonies are formed on the surface of the serum ; 
and further it is to be remembered that unless the cavity has had a 
chance of infection from without it is rare to find more than two 
or three varieties of bacteria. Great care should be taken in secur- 
ing pus, blood, or serum for cultivation that no corrosive subli- 
mate, carbolic acid, or other antiseptic comes in contact with it, as 
very minute quantities check bacterial growth even when they do 
not destroy it. 

In some instances where the bacteria are very infrequent animal 
inoculation has to be employed in order to get a correct diagnosis. 
This is especially so in cases of tuberculosis, where it may be 
practically impossible to find the bacilli of tuberculosis and their 
slow growth makes the culture-method of no value. The guinea- 
pig is by far the most useful animal for inoculation-purposes. It 



SCIENTIFIC AIDS TO SURGICAL DIAGNOSIS. 789 

is always well to use two, so as to have control and provide for pos- 
sible accidents. 

Joints. — In the case of effusions into the joints, much may be 
learned by the use of the needle. Cover-glass preparations will 
probably tell whether the condition is due to some of the pus-cocci 
— usually the streptococcus, the Staphylococcus pyogenes aureus, 
or the gonococcus. Although all may appear within the leuko- 
cytes, and the streptococcus and gonococcus look very much alike, 
yet the Gram stain will serve to differentiate them. Should, how- 
ever, there be no pyogenic cocci found either on the cover-slip or 
in the cultures, and no bacilli of tuberculosis, it would be well to 
have recourse to animals to make sure of the presence of tuber- 
culosis. Should gonococci be suspected, it must be remembered 
that they require special media for their growth ; but usually they 
can be found in the cover-glass preparations. 

The meaning which the presence of the various forms of bac- 
teria carries to the surgeon may be interpreted in general as fol- 
lows : Streptococci and staphylococci usually lead to suppurative 
conditions with destructive processes ; the gonococcus seldom pro- 
duces more than a serous effusion into the joint and mild inflam- 
matory reactions. The presence of bacilli of tuberculosis practi- 
cally always means trouble starting in the bone and from there 
invading the joint. These considerations, modified as they may 
be by the clinical picture, determine the action of the surgeon 
in the individual case he has under consideration. 

Pleura. — Where there is reason to suspect an effusion in the 
chest, the needle will show almost always the organism causing 
the inflammatory process. If the fluid is clear, the pneumococcus 
is the most common form of bacteria found ; but the bacillus of 
tuberculosis may also be found in such a fluid. If the culture- 
tubes planted from the fluid show no growth at the end of sixteen to 
twenty-four hours, and if the bacilli are not found by means of the 
appropriate staining-methods, resort must be had to animal inocu- 
lations. When pus is present in the pleural effusion the tempera- 
ture and general reaction are usually less with the pneumococcus 
than with the more virulent staphylococcus or streptococcus, and 
there is more chance of getting resolution than if these latter 
organisms are present. Where a large number of organisms are 
found, communication must have been established with the lung 
or w r ith an abscess penetrating from without or from below into 
the pleura. The colon-bacillus points especially to a sub-dia- 
phragmatic origin of the pus. In all cases the variety of the 
bacteria found is of prognostic rather than of diagnostic value ; 
but it is possible to have apparently desperate cases where the 
presence of pneumococci would decide whether or not to attempt 
to operate. 

In addition to what has already been said in regard to the 
bacteria commonly found in abscess-formation, other bacteria may 
be found in pure culture or combined with the usual forms. Thus 
pure culture of the typhoid bacillus has been noted in cholecystitis, 
and the Bacillus coli communis is common in abscesses about the 



79° SURGICAL PATHOLOGY AND THERAPEUTICS. 

bowels. In liver-abscesses the Amoebae coli may be found, or 
the hooklets of the hydatid, and at times the yellow calcareous 
granules of the actinomycetes, which of themselves are sufficient to 
give an accurate diagnosis of the condition which previously may 
have been most puzzling. 

Where anthrax is suspected, the serum from blisters about the 
wound will often show the bacilli. In pus from an anthrax 
infection of the neck it is often hard to demonstrate the large 
bacilli ; but culture or inoculation of a mouse will settle the matter 
in from twelve to twenty-four hours. 

UriJte. — The bacteria found in urine containing pus are either 
bacteria of decomposition, as found in many cases of cystitis, or 
pyogenic organisms and bacilli of tuberculosis. 

If pyogenic bacteria have been introduced through the urethra 
and found their way into the kidney, other bacteria will usually be 
found with them. 

In making a diagnosis of tuberculosis of the genito-urinary 
tract the possibility of mistaking the smegma bacilli for the bacilli 
of tuberculosis must be borne in mind, and the specimen washed 
in strong alcohol after passing through the sulphuric acid, instead 
of through the usual 60 per cent, alcohol. In cases of doubt as to 
which kidney has been infected the urine should be collected in 
the manner described in the portion of this section devoted to 
urine; and if the bacilli cannot be detected by the usual method 
of examination, some of the urine, with the sediment thrown down 
by the centrifugal machine, should be injected into a guinea-pig. 
It goes without saying, that all such urine must be collected with 
the greatest precautions to insure it from contamination. 

Urinary Conditions which are of Valne in Surgical 
Diagnosis and Prognosis. — In every operative case, as practi- 
cally in all cases, there should be a routine examination of urine to 
eliminate the possibility of renal degeneration entering in to com- 
plicate the existing surgical conditions. The presence or absence 
of a nephritis has its value in the determination of the desirability 
of an operation and its influence upon the prognosis of the case, all 
of which are to be found set forth at length in the books upon 
renal diseases. The urinary conditions, however, which it is pro- 
posed to study are those where, in the absence of so-called nephritis, 
whether acute or chronic, a single condition or chain of conditions 
may give assistance to the surgeon. 

First of all, we shall consider the amount of urine, which is of 
slight importance in diagnosis. In America the daily excretion 
seems to be less than in Europe. Whether this is because the 
dryness of our climate in summer and the similar condition of our 
furnace- and steam-heated houses in the winter cause greater 
activity of the sweat-glands, or whether it is due to other causes, 
has not been determined. Nevertheless the fact seems to be sure 
that a healthy man excretes about 1200 c.c. of urine daily, and a 
woman somewhat less. This amount is often much diminished in 
those confined by any reason to their room or their bed, and the 
same conditions affect the solid constituents of the urine. 



SCIENTIFIC AIDS TO SURGICAL DIAGNOSIS. 791 

Where the kidneys are particularly sluggish the shock of an oper- 
ation may be sufficient to produce suppression of urine. In such 
cases there seems to be a decidedly unanimous opinion that suppres- 
sion of urine is much less liable to follow operative measures if the 
urinary excretion can be increased to normal or even to more than 
the normal amount ; and surgeons feel much safer in operating 
under such conditions, even though the total amount of solids may 
have increased but slightly or not at all. 

The color of the urine will give diagnostic suggestions when it 
is smoky or dark, suggesting, as it may, the presence of blood-pig- 
ment or carbolic-acid poisoning ; bile, when the color is greenish 
or brown. The latter may be present without a corresponding jaun- 
dice of the skin, and give a hint, otherwise not obtainable, of biliary 
obstruction. It is well to remember, in this connection, that cer- 
tain drugs, as carbolic acid and salol, give peculiar color to the 
urine. In such cases the urine may be dark green or even black. 
Rhubarb and senna produce shades of brown, and santonin a yellow 
or greenish tint. Hence a few questions may prevent one being 
put on the wrong track when attempting to make a diagnosis 
from the color of the urine. If the coloring-matter in the urine 
proves to be derived from blood, the case assumes much greater 
surgical importance. First of all, the distinction is to be made 
between free blood and blood-coloring matter; between hematuria 
and hemoglobinuria. Hemoglobinuria, excepting in the case of 
bums, has little surgical significance; and here it may indicate 
much greater severity than would be supposed from the external 
appearances. 

Hematuria, on the other hand, is of special surgical significance, 
and demands careful consideration whenever it is found. The blood 
in the urine may come from any portion of the urinary tract. Bright 
blood appearing at the first part of micturition, while the urine 
voided during the latter part is partially or wholly clear, points to 
the urethra as the seat of the lesion. If, on the other hand, the act 
of micturition is closed by a few drops of bright blood, the seat of 
the hemorrhage is probably near the neck of the bladder. 

The principal vesical conditions giving rise to hematuria are 
acute cystitis, traumatism, calculus, ulcers, new growths (whether 
malignant or benign), parasites, and rupture of varicose veins. In 
case the hemorrhage is profuse, there will be blood-clots. The 
blood-corpuscles are not usually equally distributed through the 
urine, and for the most part they are of normal appearance or 
somewhat crenated. On allowing the urine to stand, the corpuscles 
tend to sink to the bottom of the glass, leaving the urine above 
nearly clear, and, if there is no nephritic complication, almost 
devoid of albumin. Should, however, there be marked alkaline 
cystitis present, the blood-corpuscles will be found to have lost 
their hemoglobin and characteristic shape, appearing simply as 
colorless spheres. 

That the blood comes from the bladder, may be made certain in 
doubtful cases by washing out the bladder and then catheterizing 
again in a short time, when the condition of the blood-corpuscles 



792 SURGICAL PATHOLOGY AND THERAPEUTICS. 

will show whether they come from the upper urinary tract or vesi- 
cal wall. 

It is very difficult to decide whether or not the seat of hem- 
orrhage is in the ureters. The worm-like clots supposed to be 
indicative of hemorrhage from the ureter may come as well from 
a hemorrhagic clot extending downward from the pelvis of the 
kidney. 

Hematuria arising from the kidney may be due to calculus, new 
growths, tuberculous ulceration, and trauma, in addition to a 
number of strictly medical conditions, which must be eliminated. 

Primary or concurrent renal disease is usually to be determined 
by the presence of urinary casts, especially if there are blood-cor- 
puscles adherent to them. At times it may be necessary to make 
a quantitative estimate of the amount of iron and of albumin pres- 
ent in a given urine, in order to decide whether there is albumi- 
nuria greater than that due to the presence of blood in the urine. 
The same methods to be detailed later in connection with renal 
pyuria are applicable to determine whether the hemorrhage origi- 
nates in the right or the left kidney, or comes equally from both. 
Carefully considered clinical history will often give a definite answer 
to many of the questions suggested, by finding the symptom of 
hematuria, and make the subsequent examinations simply con- 
firmatory. 

The further study of the sediment may also throw light upon the 
cause of the hematuria. In some instances shreds of new growth 
are found ; which should at once settle doubtful cases. The 
presence of a large crystalline deposit in the sediment would be a 
finger-mark as to the possibility and make-up of a renal or vesical 
calculus ; and although it may be unimportant to know what the 
exact form of salt is which makes up the bulk of the calculus, yet 
the presence of such a deposit may turn the scale in deciding to 
operate or not to operate where there is doubt whether the case is 
one of stone or tuberculosis. 

Pyuria, or pus in the urine, is distinctly a surgical condition. 
The pus, like the blood, may come from any portion of the urinary 
tract. The presence of a drop of pus at the meatus, following 
pressure along the urethra, indicates a urethritis. That the urethra 
alone is involved, may be determined by passing the urine into two, 
or, better, into three glasses, and allowing it to stand. If the pus 
comes from the urethra, only the first glass or the first two will be 
cloudy and contain pus in the sediment, while the last glass will 
contain practically normal acid urine. Should, however, the blad- 
der be the seat of a cystitis, the last glass will contain as much, if 
not more, pus than the first. 

When a cystitis has been present for some time, there is usu- 
ally an alkaline, foul-smelling urine. Should the urine contain 
considerable pus, and yet remain acid in reaction, tuberculosis is to 
be distinctly thought of as the cause, provided this is not contra- 
indicated by the presence of crystalline deposits, as calcic oxalate 
and uric acid. In case of marked cystitis, the pus settles as a 
stringy, sticky, adherent mass at the bottom of the glass. The 



SC/EXTIF/C AIDS TO SURGICAL DIAGNOSIS. 793 

most common causes of cystitis is retention of urine from an 
enlarged prostate. Here the age and symptoms give the probable 
diagnosis. The next most common cause, if not of equal fre- 
quency, will be the introduction of foreign bodies into the bladder 
(catheters, calculi) or ulcerations (whether tuberculous or from new 
growths). Sudden increase, followed by a slight or marked de- 
crease, in the amount of pus probably means that a pus-cavity has 
opened into the urinary tract and is draining freely. The origin 
of the abscess must be determined by the clinical symptoms. 
Further, it must be remembered that in most cases sudden disap- 
pearance of pus from the urine of a patient who has a supposed 
pyelitis does not mean that the condition has cleared up, but rather 
the reverse, bein^ a si^n that the ureter has in some way become 

POO 

plugged, and that symptoms from retained pus may be expected 
within a short time. 

To determine definitely in doubtful cases whether the pus 
comes from the bladder or from the kidney or ureter, it is well to 
catheterize and note the amount of pus in the urine. Then wash 
out the bladder with a solution of boric acid, continuing the 
process until the wash-water returns perfectly clear. The patient 
should be again catheterized at the end of an hour, and the urine 
so withdrawn compared with that first taken from the bladder. 
If both urines are of the same or nearly the same cloudiness and 
thickness, it is probable that there is pyelitis rather than cystitis. 
Should the question arise whether one or both kidneys are involved, 
the urine must be collected as it flows from the ureters. This is 
done by catheterization of the ureters — a most difficult process for 
one who has not had much practice — or by the instrument of 
Harris, which appears to answer every* purpose and can be used 
by anyone at all skilled in the use of instruments. Anesthesia 
will often greatly facilitate the process. This instrument gives 
important information where the extirpation of one kidney is con- 
sidered, showing, as it does, the condition of each kidney. It 
has happened that the surgeon has removed the only kidney that 
the patient possessed; but it would seem that in future such an 
accident should not be allowed to occur. The urethra and the 
bladder may be examined by the endoscope. Especially is this 
true of the female bladder, where the larger sized endoscopes make 
it fairly easy to get an idea of the condition of the mucous mem- 
brane of the bladder and urethra. Care and judgment must always 
be exercised to make sure that the instrumentation employed will 
yield results which shall be commensurate with the personal dis- 
comfort of the patient and the local irritation of the canals. 

Chlorides in the urine are said to be markedly diminished in all 
cases of carcinoma ventriculi. Probably this phenomenon does 
not occur until later in the disease than would make it of value in 
diagnosis in early cases when operation for cure might be considered. 
Nevertheless, it is well to consider the amount of chlorides as 
confirmatory evidence in cases of suspected cancer of the stomach, 
remembering that there may be marked diminution also in cases of 
dilatation of the stomach with hypersecretion of the gastric juices. 



794 SURGICAL PATHOLOGY AND THERAPEUTICS. 

Urea is much diminished in certain liver diseases, and among 
them carcinoma. 

Where the separate secretion of the two ureters has been secured, 
it may prove of value to know which kidney is functionally the 
better, as found by the quantitative estimation of the urea in each 
specimen. It may be demonstrated by this means that, though 
one kidney shows greater activity of the destructive process, the 
other in reality is less valuable as an excreting organ. 

Indican in normal conditions is produced in the large intestine; 
and diseases of the large intestine alone are never associated 
with increase in indican. If indican is produced in excess of the 
normal amount in the large intestine, it is due to the action of 
putrefactive bacteria, either developing in the intestine under favor- 
able conditions or when the indol-producing bacteria cause an albu- 
minous putrefaction in certain conditions, as gangrene of the lung, 
putrid bronchitis, etc. The greatest amount of indican in the 
urine is found in intestinal obstruction, especially if located in the 
ileum. This may be a diagnostic hint of the greatest importance, 
since the amount of indican in such a condition is greater than it 
would be in local or general peritonitis or in the stomachic condi- 
tions associated with diminished and absent hydrochloric acid secre- 
tion, in which cases the amount of indican is also increased. 

Sulphates are of two groups — preformed and conjugate. The 
latter are markedly increased in obstructive jaundice, returning to 
normal when the bile-passages are again opened to the intestine. 
In cases of non-obstructive jaundice the total sulphates is dimin- 
ished. These facts may prove of value in getting all possible data 
for the expediency of an operation in an obscure case of jaundice. 

Spinal Puncture. — Possibly none of the expedients by which 
accurate diagnosis is sought for yields such uniformly positive 
results as does spinal puncture. The amount of the fluid, in the 
first place, with the addition of leukocytes and blood-corpuscles, 
shows whether one has to do with an inflammatory or a hemor- 
rhagic process. 

The bacteria found in the cells or fluid, or developing when this 
fluid has been planted upon blood-serum, give the cause of the 
meningitis. Should tuberculosis appear probable, animal injec- 
tions have to be resorted to in many cases, in order to demonstrate 
the bacilli. 

The presence of blood, leukocytes, or bacteria, as the case 
may be, is so constant in morbid conditions, that where one gets a 
negative observation in case of spinal puncture and does not find 
these elements, it is of much greater value than the usual negative 
bacterial or microscopical examination. The latter usually means 
simply not found, but in spinal puncture it means that these diag- 
nostic elements are not present. No case of accident has been 
reported from spinal puncture, and in many instances favorable 
therapeutic results follow withdrawal of the fluid ; hence no one 
should hesitate to use spinal puncture wherever it seems probable 
that any information may be obtained as to existing meningeal 
conditions. 



SCIENTIFIC AIDS TO SURGICAL DIAGNOSIS. 795 

Feces. — The microscopic examination of the feces offers but 
little aid to surgical diagnosis. Pus in quantities sufficient to be 
seen with the naked eye indicates an active inflammatory process 
or the presence of an abscess discharging into the rectum. Small 
amounts seen only on microscopic examination show but little, 
as any ulceration or inflammatory process will produce some pus ; 
and therefore, more than confirming the opinion that one has to do 
with some intestinal or peri-intestinal condition causing ulceration, 
nothing can be determined. 

The search for and finding the A?ncebcz colt in the feces in cases 
where there are symptoms of abscess in or about the liver would 
be of positive value in diagnosis, giving a definite causal element 
for the evolution of an hepatic abscess. 

The presence of other intestinal parasites, or their eggs, in the 
stools in rare cases may suggest an explanation of otherwise obscure 
symptoms. 

Search for the bacilli of tuberculosis in intestinal conditions may 
give positive results and -prove of great satisfaction. Here it is 
well to dilute the feces with water, shake them vigorously, and 
allow them to stand. The portion for examination is taken from 
the layer just above the deposit of solid materials at the bottom 
of the jar. 

Cellular elements, represented by fragments of tissue from an 
ulcerated surface, do not establish a diagnosis, as there is no way 
by which cancer-cells can be differentiated from ordinary prolifera- 
tion-cells coming from any ulceration-process. 

Blood-corpuscles are never found in the stools, even when the 
fecal matter is bright red, unless the seat of the lesion is below 
the ileocecal valve. Practically the only exception to this is 
where severe hemorrhage occurs accompanied by diarrhoea, as in 
typhoid fever, where large blood-clots are passed so rapidly that 
decomposition of the corpuscles does not have a chance to take 
place. Where small amounts of blood occur, this fact will help to 
localize the lesion. 

Microscopical Examination of Pieces of Tissue Suspected 
of being of Malignant Growth. — The diagnostic and prognostic 
importance of the examination of tissue suspected of being malig- 
nant is perfectly clear to all. All tumors upon the surface of the 
body can be investigated before operation, by securing a piece of 
the tissue and submitting it to a competent pathologist for exam- 
ination. 

In many cases it is possible to have a pathologist present at an 
operation, and to get from him exact data in regard to the extent 
of involvement of surrounding tissues, especially neighboring 
lymph-glands, and so determine the extent to which it is neces- 
sary to operate. The presence of the pathologist is of great 
value to the surgeon, who can thus devote his whole attention to 
the technique of the operation, going ahead in his dissection as 
long as the pathologist tells him it is necessary. 

In cases where pieces of tissue are to be obtained for diagnosis, 
a number of considerations must be complied with to enable the 



796 SURGICAL PATHOLOGY AND THERAPEUTICS. 

pathologist to make a satisfactory report on the question submitted 
to him. 

First and most important is that the piece of tissue taken from 
the suspected growth should be large enough to show clearly the 
cellular structure. Care especially should be taken, in securing 
pieces from an ulcerated surface, not to take the hypertrophied 
tissue alone. In all such conditions, both malignant and benign, 
the microscopic appearances are too nearly alike to permit of any 
sure differentiations. A thin piece extending deeply into the 
healthy tissues is what is desired, rather than a broad superficial 
portion. In all cases it is necessary to include in the specimen a 
portion of the normal tissue ; and this must be done even if it 
involves the necessity of putting in a catgut suture to check the 
immediate hemorrhage and close the gap. With the complete local 
anaesthesia to be obtained by the infiltration of cocaine, there is 
almost no part of the surface of the body that is not accessible for 
such preliminary examination. 

In the case of hyperplastic endometritis, where it is frequently 
desired to determine the character of the scraping from the uterine 
cavity, it is necessary to observe the same general principles just 
laid down. The curetting should be carried deeply enough, so that 
there shall be some portion of the uterine tissue in the scrap- 
ings. These should be washed in water to remove all the blood- 
clot, and then the tissue should be rolled into a ball for con- 
venience in handling and cutting. If there is no doubt that the 
tissue will reach the pathologist within twenty-four hours and 
in good condition, it is well to send the specimen wrapped in a 
damp cloth or piece of gauze, and this packet enclosed in oiled 
silk or waxed paper. In cases where the specimen might become 
dried or not reach the laboratory till after this period of time, a 
small bottle should be filled with alcohol (about 95 per cent), and 
a small bit of absorbent cotton placed in the bottom of the bottle, 
and into this alcohol the rolled-up mass of scrapings should be 
dropped. There should be a label upon the bottle, giving the date, 
the address, and, not less important, the portion of the body from 
which the specimen has been taken. Nothing is more provoking 
to a pathologist than to be asked to examine something with no 
hint as to what is wanted. In many cases he can tell what is 
expected ; but this is from long experience ; and time will be 
saved if it is plainly stated whence the specimen was obtained and 
what is suggested by the clinical conditions. The same is true 
of material sent for bacterial examination. Always state where 
the material comes from, and what forms of bacteria you specially 
want it examined for, as the methods of examination differ greatly 
for different organisms. 

Should, for any reason, it be necessary to keep the specimen 
for several days before getting it to a pathologist, it is well to 
change the alcohol each day ; do not be afraid to use a good deal 
of alcohol. 

Rontgen Rays in Surgery.— The application of skiagraphy to 
surgery is necessarily limited, and must remain so, because we are 



SCIENTIFIC AIDS TO SURGICAL DIAGNOSIS. 797 

dealing with that which casts a shadow according to the density 
of the part or object and the impervionsness of the same to the 
A'-rav. By means of skiagraphy we can determine with almost 
absolute accuracy the presence of foreign bodies in any part of the 
body, provided, of course, that the foreign body be opaque to the 
X-ray. In order to do this accurately, it is necessary to take at 
least two plates at different angles, as one plate alone may be very 
misleading. The surgeon may thus be guided as to what opera- 
tion is best or whether operation is advisable. It is not always 
necessary to take skiagraphs of foreign bodies, as their presence or 



Fig. 133. — Fracture of the neck of the femur. 

absence can oftentimes be demonstrated with the fluoroscope, 
when by marking on the skin the exact location can be found. 
Some of the more difficult objects to locate are glass splinters, 
rubber drainage-tubes, and aluminum splinters. The value of 
skiagraphy in determining the presence of foreign bodies in the 
eye is very great, and special apparatus and technique have reached 
such perfection that it can be done with great accuracy. 

The next important branch of surgery to which skiagraphy is 
applied is that of fractures. To have at hand the means by which 
an accurate diagnosis can be made in doubtful cases or in cases 



SURGICAL PATHOLOGY AND THERAPEUTICS. 



where swelling of surrounding tissue is so great that palpation is 
impossible, is certainly of great value ; and in skiagraphy we have 
that means. Its application to fractures of the skull is as yet of 
no value ; and, of course, great difficulty is experienced in fractures 
of the scapula, sternum, and pelvis. In fractures about the 
shoulders and hips, owing to difficulty in getting a lateral view, 
the extent of fracture or displacement often cannot be accurately 
ascertained (Fig. 133). The above applies equally to dislocations 
(Fig. 134). The skiagraph is of value not only in confirming the 
diagnosis of fractures, but also to a limited extent in treatment, as 
after fracture is reduced the skiagraph will demonstrate the degree 




Fig. 134. — Dislocated patella. 

of reduction. The surgeon can thus see whether it is advisable 
to attempt further correction ; and also as to the advisability of 
refracture in cases with much deformity. Skiagraphy is also of 
value in fractures about the joints, in exostoses, bony tumors, and 
necrosis. The extent of diseased areas can in many cases be dem- 
onstrated ; also ununited fractures, epiphyseal separations, and 
congenital dislocations. Spinal caries can also be detected. 

As yet, comparatively little has been accomplished in detecting 
renal calculi. Much work has been done, of a very encouraging 
nature ; but much more must be done in order to convince the 
surgeon that calculi are present or absent from evidence furnished 
by the skiagraph alone. Some observers maintain that a positive 



SCIENTIFIC AIDS TO SURGICAL DIAGNOSIS. 



799 



diagnosis can be made by this means as to the presence or absence 
of calculi, no matter what the composition of the stone may be. 
This lacks confirmation, and certainly seems very doubtful. If 
true, it shows a wonderful advancement in technique as well as in 
apparatus, and certainly will be of vast value. Renal calculi have 
been located by skiagraphy and removed by operation ; but so far 
only those composed of oxalate or phosphate of lime (see Fig. 135). 




Fig. 



:35. — 1, drainage-tube; 2, 3, 4, 5, renal calculi composed of oxalate of lime (case of 

A. T. Cabot). 



Uric-acid calculi cast so slight a shadow — barely more than that of 
the surrounding tissue — that it seems impossible to locate stones of 
this type by means of the X-ray. Organic matter casts so slight a 
shadow that it is very doubtful as to the possibility of demonstrat- 
ing the presence of either uric-acid calculi or gall-stones. 

The disadvantages of the X-ray in its application to foreign 
bodies are practically nil, but in regard to fractures there are 
many. We must bear in mind that a skiagraph is a shadow- 
picture, and that necessarily in some parts of the body a skiagraph 
will always show more or less distortion. There is some distortion 
under the best conditions, and it is a simple matter to exaggerate 
any deformity or displacement that may exist. This is of consid- 
erable importance, as already the skiagraph has been accepted as 
evidence in court. If the skiagraph is to be admitted as evidence, 
positive proof should be furnished that certain conditions giving 
correct results have been complied with. Even then the advisa- 
bility of such evidence is questionable, for in many cases complete 
reduction of a fracture is impossible, and in many such cases the 



800 SURGICAL PATHOLOGY AND THERAPEUTICS. 

skiagraph is somewhat startling to the layman's eye, yet function- 
ally the results may be almost perfect. 

The manipulations of the surgeon may occasionally reveal what 
the skiagraph fails to do. In such cases a fracture may sometimes 
be demonstrated by the skiagraph if the surgeon use some force to 
separate or rotate the fragments. Skiagraphy must, therefore, not 
be considered an absolute method of diagnosis in fracture, but 
simply an aid in this branch of surgery. 

The so-called X-ray dermatitis is produced by long exposure at 
short range. This complication does not occur when the apparatus 
is placed at a distance of twelve to thirteen inches from the surface 
of the body. In 4500 cases of exposure at the Massachusetts 
General Hospital, ranging from one minute to two hours, no 
dermatitis occurred. During the period covered by these observa- 
tions eight cases of dermatitis have been observed, all of which 
were caused by near exposure. The peculiar form of apparatus 
employed did not seem to be a factor in the production of the 
inflammation, as in no two cases was the same form employed. 



II. SURGICAL BACTERIOLOGY OF THE 5KIN. 

The surface of the human body is the natural habitat of many 
different forms of bacteria. The essential conditions for bacterial 
growth — warmth, moisture, and nutrient material — are all present ; 
and in spite of a certain amount of germicidal power which has 
been found in certain cases to be present in the skin (Binaghi) 
abundant culture-growths can be obtained from the skin of every 
individual. Some parts of the body, as the axillae and the sub- 
ungual spaces, afford more favoring conditions for growth than 
other more exposed parts, and there seems to be also a variation to 
a certain degree between one individual and another. The con- 
stant presence of bacteria, however, upon the surface of the human 
body has led to much study in connection with wound-treatment 
and aseptic surgery. 

The pathogenic bacteria most commonly found upon the sur- 
face of the body are as follows : Staphylococcus pyogenes aureus, 
albus, and citreus (Passet) ; Staphylococcus epidermidis albus 
(Welch), Staphylococcus viridis flavescens (Babes), Staphylococcus 
cereus albus (Tavel), Staphylococcus cereus flavus (Passet), Staphy- 
lococcus gilvus (Robb), Micrococcus tetragenus, Streptococcus, 
Bacillus pyocyaneus (Gottstein), Bacillus proteus (Binaghi), Bacil- 
lus coli communis (Binaghi). In addition to these forms, almost 
any of the other bacteria which are pathogenic to man may be 
found under certain conditions, although so rarely as safely to be 
disregarded in connection with wound-infection. 

The bacterium most commonly met with in skin bacteriology 



SURGICAL BACTERIOLOGY OF THE SKIN. 801 

is without doubt the Staphylococcus albus ; and a form of this 
organism has been described by Welch as being a constant inhabi- 
tant of the follicles and the deeper layers of epithelial cells of the 
human skin. That this organism differs essentially from the 
Staphylococcus pyogenes albus is not definitely decided ; but the 
probability exists that the form described by Welch is rather an 
attenuated form, and that under such favoring conditions as are 
afforded by the presence of drainage-tubes or necrotic tissue in a 
wound, the pus-producing function may be acquired. 

The Pyogenes aureus and the streptococci also vary in viru- 
lence, although not reaching such a degree of attenuation as the 
albus. As a rule, they always produce pus. Many instances are 
cited, however, where, although aureus was present in wound-secre- 
tion or upon stitches, healing proceeded uninterruptedly by first 
intention. 

The Bacillus pyocyaneus is another germ which appears fre- 
quently in septic wounds, giving the characteristic blue or green 
color to the pus ; and it is interesting to note that this is one of 
several bacteria which especially endure drying and can be trans- 
ported for long distances in currents of air (Neisser). 

The characteristic peculiarities of these several forms of bac- 
teria will be found elsewhere (under the section on Surgical Bac- 
teria), and no further discussion of them is necessary in this con- 
nection. 

The constant endeavor in surgery has been to obtain perfect 
wound-healing. The greatest contribution to this end was un- 
doubtedly the work of Lister, and his use of carbolic acid marked 
the beginning of modern surgery. Since that time, however, one 
germ after another has been found to be capable of setting up sup- 
puration in a wound, and we have come to look upon perfect 
wound-healing as demanding absolute asepsis — the total absence 
of bacteria. Healing by first intention, however, does not in the 
least imply a total absence of bacteria : it implies rather that there 
is present in the wound only such a quantity of bacteria as can be 
overcome by the natural germicidal power of the tissues and the 
wound-secretions. This germicidal action of fresh wounds is 
found to be most powerful in the first twenty-four to forty-eight 
hours, and it is found to differ in individuals, and probably in the 
same individual at different times (Schloffer). Furthermore, the 
conditions which favor bacterial growth, such as necrotic tissue, 
"dead " spaces, and foreign bodies, as pointed out by Welch, vary 
in different wounds ; and it is readily understood that with so 
many varying conditions the desired first intention may fail in any 
given case and the reason be difficult to find. The surgeon, how- 
ever, who realizes the dangers of all these conditions, and so acts 
in any given case as to avoid as many as possible of the conditions 
favoring wouud-infection, will obtain the best results. 

Avoidance of Wound-infection. — Absolute and continuous 
sterility of the field of operation, both superficially and in the 
deeper layers of the epidermis, seems with our present methods to 
be unattainable. The number of germs, however, and their 

51 



802 SURGICAL PATHOLOGY AND THERAPEUTICS. 

vitality can be markedly diminished by several procedures, both 
mechanical and chemical. 

Mechanical. — (a) Scrubbing with a clean brush and soap and 
water. This removes gross macroscopic dirt ; masses of fat in 
which germs are imbedded and protected from the antiseptic solu- 
tions we wish to use later ; the actual germicidal power of soap 
solutions is too weak to be worthy of attention. 

(b) Shaving. — Removing the hair and also the outer scales of 
the epidermal layer. 

Chemical. — (a) Cleansing. — Here again soap and water must be 
considered, by reason of the solvent action on fats ; this action, 
however, being inferior to that of alcohol or turpentine. Alcohol 
combines, with the cleansing action, a certain antiseptic power 
also, and seems to prepare the way for the better action later of 
the antiseptic solution. It mixes readily with water, and as such 
is to be preferred to ether. Turpentine is irritating and inferior 
to alcohol. Alcohol is best used in 80 to 90 per cent, concentra- 
tion. 

(b) Disinfection. — The number of drugs which have been found 
to have a germicidal action upon bacteria are so numerous that a 
detailed account of the value of each is beyond the scope of this 
section. In a general way, however, the drugs used in surgery 
fall into one or another of the following classes : 

1. Mercurials : bichloride, iodide, oxycyanate. 

2. Carbolic acid group : carbolic acid, sulpho-naphthol, lysol. 

3. Gases : chlorine, formaldehyde. 

^4. Silver and its salts : lactate, citrate, nitrate. 

5. Other drugs : permanganate of potassium, oxalic acid, per- 
oxide of hydrogen, iodoform, boric acid, etc. 

Corrosive sublimate, or bichloride of mercury, is the antiseptic 
agent most frequently used in surgery, and may be regarded as the 
type of the mercurial antiseptic. It is effective in killing germs 
when it can be brought into close contact with them in a strength 
of 1 : 20,000. In actual practice, however, much greater concen- 
tration is necessary, as the bacteria lie imbedded in fat and dirt, and 
are not readily accessible to the germicide on the surface of the 
body. When used in wounds corrosive sublimate has two disad- 
vantages — first, that the body-tissues enter into chemical combina- 
tion with the mercury and form an insoluble and inert albuminate; 
and secondly, as shown by Halsted, that the use of even very weak 
solutions produces a necrosis of the superficial layers of the tissue 
with which they come in contact. The first of these disadvantages 
may be overcome by the addition of common salt or of ammonium 
chloride to the solution, whereby the albuminate is less readily 
precipitated; but for the necrosis there is no help. 

Carbolic acid is the original antiseptic introduced by Lister. It 
is germicidal in a strength of 1 : 100. Its chief advantage is its 
ability to penetrate greasy substances, and its chief disadvantage 
its irritative properties, both local and remote. It is readily 
absorbed, and produces toxic symptoms, chiefly in the kidneys. 
To this group belong lysol, kresol, and sulpho-naphtol, both less 



SURGICAL BACTERIOLOGY OF THE SKIN. 803 

potent and less irritating- than carbolic acid. Lysol is used by 
Mikulicz in 1 per cent, solution. Sulpho-naphtol may be used in 
2 per cent, solution. 

The gases, formaldehyde and chlorine, have been used only 
recently for disinfection of wounds, although long known to be 
powerful disinfectants. They are very effective germicides, but 
unpleasant and undesirable on account of their irritating fumes. 
Formaldehyde is now used as formalin (a 40 per cent, solution of 
the gas in water). Formalin, 1 part to 100 of water, is used on the 
surface of the body, and gives a sterile operation-field in 80 to 90 
per cent, of the cases. This is as much as can be claimed for any 
method of skin-sterilization. Applications of this strength must 
not be allowed to remain over twenty-four to thirty-six hours in 
contact with the skin, as a hardening of the skin will follow, and 
delayed union or even necrosis result. Weaker solutions are used 
for irrigation and dressings, but cause considerable pain. Glutol 
(formalin-gelatin) is also used for dressings, and has marked anti- 
septic properties. Nascent chlorine is used, as suggested by Weir, 
in preparation of the skin of the patient and of the surgeon's 
hands. A tablespoonful of chlorinated lime and the same amount 
of washing-soda are placed in the palm of one hand, and enough 
sterile water added to form a creamy paste ; this paste is rubbed 
into the skin for about five minutes and is then washed off with 
sterile water. A large percentage of sterile results is claimed for 
this method, but the fumes of the nascent chlorine are very irritat- 
ing and decidedly disagreeable. 

The salts of silver are used to a much greater extent as anti- 
septics abroad than in America. The expense and the need of 
freshly prepared solutions at frequent intervals have worked against 
their adoption in this country. The citrate (itrol) and the lactate 
(actol) are effective germicides in 1 : 1000 solution, and are to be 
preferred to argonin and argentamin (Blumberg) and to the com- 
mon silver nitrate. 

Permanganate of potassium and oxalic acid used in sequence, as 
recommended by Schatz, and later by Kelly, are effective in satur- 
ated solution, but are very, irritating. The use of peroxide of 
hydrogen to complete the oxalic decolorization diminishes the 
annoyance to a certain extent without loss of effect, but the irrita- 
tion caused to the surgeon's hands by this method, when used as 
freely as a busy hospital-service demands, is a serious disadvantage. 

Salicylic and boric acids, styrone, iodoform, and other drugs 
have a certain amount of antiseptic power, but cannot be relied 
upon to kill the bacteria in any concentration which it is possible 
to use. They rather retard the growth of bacteria, and are of 
more value in wound-treatment than in obtaining sterile surfaces. 
This retarding of the growth of bacteria has been studied by 
Welch, who finds that even corrosive sublimate may have only a 
temporary germicidal action, and that a certain number of the 
germs may be resuscitated, as it were, by the application of chemi- 
cals, like ammonium sulphide, which precipitate the mercury and 
allow the bacteria to come to life again. This suggests a union 



804 SURGICAL PATHOLOGY AND THERAPEUTICS. 

of the mercurial salt with the germ-envelope, or some such 
chemical reaction, which inhibits growth so long as the combina- 
tion exists, but does not totally destroy the living organism. 

Absolute asepsis in surgery is a goal toward which every one 
must strive, but which few can attain. This is not hard to believe, 
when we consider the number of factors which enter into the ques- 
tion. First, the skin in which the wound is to be made contains 
countless germs, many of which if inoculated in sufficient quantity 
may produce suppuration. Secondly, the hands of the surgeon are 
of necessity subject to repeated contaminations and are extremely 
difficult to render absolutely sterile. Thirdly, the air of the 
operating-room is a source of infection which cannot with perfect 
safety be disregarded. Inanimate objects, which can be subjected 
to dry heat or steam, or which are not injured by the application 
of concentrated solutions of certain germicidal power, can be made 
absolutely free from living bacteria, and all that then remains to do 
is to keep them sterile. Instruments can be boiled, silk and gauze 
can be steamed; but the living tissues of the patient and the hands 
of the surgeon can obviously be treated with neither steam nor 
heat. Even the stronger and more certain germicides are useless 
for this purpose, because of their caustic and irritating effects upon 
all living tissues; and the sterilization of the patient's skin and the 
surgeon's hands is thus the greatest problem at the present time in 
surgical technique. 

We have seen, however, that absolute asepsis is not needed for 
the best results .in surgery. Primary union can be obtained with a 
certain number of bacteria in the wound; and the surgeon must 
therefore rely upon the patient's tissues to dispose of the few germs 
which, in spite of his best efforts, will occasionally reach the 
wound during the operation. The methods adopted by those 
whose statistics show the best results must, therefore, be taken as 
the standard of surgical procedure, and for this reason a short 
resume of several methods of technique may here be given : 

Operation-field. — i. Alcohol and Corrosive Method. — (a) Shave ; 
(b) Scrub with potash soap and soft hot water for five minutes ; (c) 
Alcohol, 90 per cent. ; scrub for three minutes ; (d) Corrosive sub- 
limate, 1 : 1000, for eight minutes. 

2. Nascent Chlorine Method. — (a) Shave ; (b) Scrub with soap 
and water for five minutes; (V) Washing-soda, jounce; chlorinated 
lime, y 2 ounce, mixed and diluted to a creamy consistency with 
water, and rubbed into the skin for three minutes; (a) Wash with 
sterile water. 

3. Permanganate and Oxalic Method. — (a) Shave; (b) Scrub 
with soap and water for five minutes, rinse off; (c) Saturated solu- 
tion of permanganate of potassium for two minutes; (d) Hot satu- 
rated solution of oxalic acid till stain is nearly gone; (e) Peroxide 
of hydrogen to complete decolorization ; (f) Corrosive sublimate, 
1 : 1000, for two minutes. 

These three standard methods may be modified in many ways 
and to suit the taste of the surgeon or the peculiarities of the indi- 
vidual case. A poultice of green soap (one teaspoonful to the pint 



SURGICAL BACTERIOLOGY OF THE SKIN. 805 

of water) may be applied after shaving the part, and be allowed to 
remain for from four to twelve hours before the antiseptic solutions 
are applied. A minimum number of bacteria, however, may be 
expected to survive in the deeper skin-layers in a certain percent- 
age of cases after every one of these preparations. 

4. Formalin. — (a) Shave ; (b) Scrub with soap and water for 
five minutes ; rinse off; (c) 1 per cent, formalin solution, by poul- 
tice, for twelve to thirty-six hours (frequently changed) ; (d) Alco- 
hol, 90 per cent., for one minute ; (e) Corrosive sublimate, 1 : 1000, 
for two minutes. 

By this method the formaldehyde-gas penetrates the follicles 
and deeper layers of the skin, and, as reported by Landerer, gives 
a sterile operation-field in 80 to 90 per cent, of cases, or primary 
union in 100 per cent. (Brewer). Care must be taken that the 
formalin solution be not in contact with the skin for more than 
twenty-four to thirty-six hours, as a hardening of the tissues and 
delayed union may result. 

Surgeon's Hands. — Any of the above methods of skin-disinfec- 
tion, except formalin, may be used for the sterilization of the sur- 
geon's hands, and large numbers of culture-tests are reported to 
prove the efficacy of each method. As a fact, however, surgeons 
have felt so little confidence that absolute safety could be obtained 
by these methods in every case, that various methods for covering 
the hands have been advocated, and the operating-glove has obtained 
a place in the surgeon's list of apparatus. 

Halsted introduced rubber gloves in 1889, first for his assist- 
ants, and later for himself. The rubber glove is impervious until 
torn or punctured, and can be boiled and sterilized to a certainty. 
For such operations as do not require the utmost delicacy of 
manipulation, the rubber glove gives admirable security against 
infection from the surgeon's hands. 

Mikulicz sought to obviate the annoyance of the rubber glove 
by substituting common white-cotton gloves, which were sterilized 
by steam; and this procedure has been widely adopted. When wet 
with blood, cotton gloves are readily pervious to bacteria, how- 
ever; so that, to be other than a source of danger, they must be fre- 
quently changed during the operation, and the hands prepared as 
carefully as when operating without gloves. Paraffined gloves and 
leather gloves have been used; but they offer no especial advan- 
tages over rubber and cotton gloves. Doderlein found that the 
hand remained sterile inside the rubber glove; and argues from 
this that the germs found so uniformly on the operator's hand at 
the close of the operation come rather from the air and the imper- 
fectly sterilized skin of the patient than from the sweat-glands of 
the operator's hands. Whatever the source of the infection, it 
seems certain that the glove is a powerful agent in securing union 
by first intention and in protecting the hand of the operator from 
infection, and, as such, is a valuable addition to surgical tech- 
nique. 

Infection of wounds from the air was thought by Lister to be 
of frequent occurrence; and it was to prevent this infection that 



8o6 SURGICAL PATHOLOGY AND THERAPEUTICS. 

the carbolic spray was designed. Later, however, when more 
emphasis was laid upon the hands and patient's skin, as carriers 
of infecting germs, less weight was put upon air-infection ; it is 
only comparatively recently, from the investigations of Flugge, 
Neisser, and others, that we have been taught that the air itself, and 
the fine droplets of moisture which are present in the surrounding 
air when laughing, talking, or sneezing occur, may carry a consid- 
erable number of pus-producing organisms and deposit them upon 
the wound. Mikulicz and others wear masks of fine gauze while 
operating, to avoid this manner of infection. The mask is in 
itself so irksome an appliance that we may feel at liberty to disre- 
gard this additional precaution in the greater number of cases, 
while improving our technique in other directions ; provided 
always that the surgeon recognizes the danger of talking or cough- 
ing, and avoids them as much as possible. 

Gauze and linen for sponges, dressings, gowns, tozvels, etc. can 
be sterilized by steam under pressure or in the Arnold sterilizer ; 
best of all, perhaps, by the fractional method of half an hour on 
three successive days. By this method the spores which are not 
killed at the first heating grow into adult forms in the interim, 
and are killed at the second and third sterilizations. Copper 
canisters, or even cotton-cloth wrappers, will protect for at least 
four weeks dressings sterilized in this way. 

Instrume?tts may be sterilized by boiling ten minutes in water 
to which have been added a few teaspoonfuls of sodium carbonate, 
or by exposing to formaldehyde- vapor from ten to fifteen minutes. 
The latter method is recommended for fine instruments, as in oph- 
thalmology, because it does not injure the cutting-edges ; but, for 
simplicity, boiling is much to be preferred, and little injury to the 
instruments will result if the addition of the soda be rigidly ad- 
hered to. In addition to protecting the instruments from rust, the 
soda increases the efficacy of the sterilization, as shown by Schim- 
melbusch, by its solvent action upon the gross dirt and the pro- 
tective envelopes of the germs. 

Sutures and ligatures have probably caused as much discussion 
in surgery as any other factors entering into wound-treatment; and 
undoubtedly more unjust accusations have been brought against 
them, whether silk or catgut, than they deserve. As a fact, any 
ligature-material can be rendered aseptic before it is placed in a 
wound ; and where the material is thought to have been septic, 
from failure of primary union, in many cases the cause is to be 
sought rather in an infection of the material by the surgeon or 
by the patient's skin at the time of operation. In this connec- 
tion, catgut is far more liable to produce trouble than silk, because 
of the fact that catgut is in itself a favorable medium for the 
growth of bacteria, while silk is not. Add to this the fact that a 
catgut strand needs to be two or three times as great in diameter 
as a silk one of the same strength, and it is obvious that the 
larger foreign body is the one more liable to favor infection. 
With absolutely sterile hands and operation-field, catgut is as little 
liable to produce suppuration as silk ; catgut may be sterilized by 



TREATMENT OF WOUNDS. 807 

any one of several methods, that by boiling in cumol, as modified 
by Clark and Miller of Baltimore, being perhaps the best. 1 

Silk and silkworm-gut can, of course, be boiled or steamed, and 
are therefore to be relied upon. 

A recent modification of suture-material has been introduced 
abroad, and is perhaps a return to earlier principles in that the 
antiseptic rather than the aseptic suture is coming to the front 
again. This is due to the general realization of the fact that the 
deep layers of the epidermis cannot be rendered aseptic in every 
case with any one of our present methods of preparation, and to 
the desire on the surgeon's part to prevent the growth of those 
germs which he is at present unable to kill. For this purpose 
iodoform, alcoholic and silver preparations of silk have been de- 
vised ; but, owing to the retarding action of all antiseptics upon 
cell-growth and wound-healing, there is much to be said in opposi- 
tion to them as well as in their favor. 

Catgut is to be preferred to silk where suppuration is inevitable. 

Silkworm-gut is the best material for skin-sutures, its greatest 
advantage beins: due to the fact that it is non-absorbent and readilv 
sterilized. The manner of sterilization is unimportant, as any one 
of the recognized methods will give sterile results if properly 
carried out. 

Absolute asepsis, then, is an ideal; and, however much desired, 
cannot be obtained in every wound with our present methods of 
procedure. Fortunately, however, this absolute degree is not 
essential for perfect wound-healing, and many series of cases are 
now reported in which healing by first intention occurred in 100 
per cent, of the cases. 

The greatest obstacles to continuous asepsis are the skin of 
the patient and that of the surgeon's hands. The procedures, 
however, described above have already succeeded, in the hands 
of certain surgeons, in producing perfect results ; and a pains- 
taking adjustment of these precautions in every individual case 
should never fail to reduce the number of bacteria to a quan- 
tity so small as to be easily conquered by the natural resistance of 
the patient. 

TREATMENT OF WOUNDS. 

The end and aim of all wound-treatment are to obtain perfect 
healing — a rapid union of the surfaces in apposition with as little 

1 The Kr5nig method of catgut sterilization, as modified by Clark and Miller of Johns 
Hopkins University, is as follows : 

1. The gut is cut in suitable lengths, and several pieces are wound into figure-of-eight 
shape, of a size to fit into an ordinary test-tube. 

2. These pieces are placed on cotton in a jar and gradually raised to 8o° C, at which 
temperature they remain for one hour, to drive off all water. 

3. The catgut is then placed in cumol at ioo° C, in a vessel surrounded by a sand- 
bath, care being taken that the catgut does not touch the sides or bottom, but rests upon wire 
gauze or cotton. The temperature is then gradually raised to 165 C, and kept there for 
one hour. 

4. The cumol is poured off. and the heat of the sand-bath allowed to dry the catgut. 

5. The dried catgut is picked up with sterile forceps and placed in test-tubes which 
have been previously plugged with cotton and sterilized, and in this way is kept until used. 



808 SURGICAL PATHOLOGY AND THERAPEUTICS. 

systemic disturbance as possible. The measures at our command 
are practically those which have been discussed in the section upon 
Skin Bacteriology, and their application alone requires modification 
to suit the individual case. 

In a wound of any sort, whether made by the surgeon's knife, 
under practically aseptic conditions, or by an accidental injury, 
under conditions not at all aseptic, certain principles of treatment, 
if faithfully carried out, will be found to contribute much toward a 
union by first intention. 

i. The wound must be made clean of foreign matter, both 
gross dirt and microscopic germs. 

2. Necrotic or strangulated tissues, of uncertain vitality, must 
be removed. 

3. The wound must be dry, and hemorrhage must be effectu- 
ally controlled. 

4. Where copious oozing is inevitable, or where doubt exists as 
to the cleanliness of the wound, provision must be made for the 
escape of fluids. 

5. The cut surfaces must be brought together under as little 
tension and with as few stitches as possible. 

6. A proper covering must be provided to absorb discharges 
and protect the wound from contamination. 

7. The wound must be placed and kept in a position such that 
tension is relieved and motion restricted as much as possible. 

These principles of wound-treatment may be observed in widely 
different methods and with many different agents, according to the 
resources and taste of the surgeon and the needs of the individual 
case ; but the principles remain the same, and are not with safety 
to be disregarded. 

Cleanliness. — Wounds made by the surgeon under aseptic condi- 
tions may need no cleansing whatever at the close of the operation: 
after any prolonged operation, however, a flushing of the wound with 
warm sterile salt-solution (NaCl 3J to water Oj) will carry off certain 
of the germs which have entered the wound in the course of the 
operation, and will in no way retard the healing process. Wiping 
the cut edges of the skin with stronger antiseptics, as 2 per cent, 
peroxide of hydrogen or formalin, is recommended by some 
surgeons, in order to destroy such germs in the deeper layers as 
may have escaped the preliminary preparation, and threaten the 
failure of first intention by stitch-abscess. 

Wounds made under non-aseptic conditions, however, require 
much more painstaking cleansing, and the time spent in these 
procedures may often determine the question of life or death to the 
patient. Not the wound alone, but the skin of the surrounding 
parts, must be made as nearly aseptic as possible, unless the de- 
lay is directly contraindicated by such a condition of hemorrhage 
or shock as to threaten life. The hair of the surrounding skin 
must be shaved, and the skin surface scrubbed with soap and 
water, and then with 90 per cent, alcohol. Where greasy sub- 
stances, as oil or wheel-grease, are present near the wound, as upon 
the hands of an engineer or mechanic, a 1:10 solution of liquor 



TREA TMENT OF WOUNDS. 809 

sodce chloratae may be used with very good effect. After these 
preliminary steps the wound must be thoroughly laid open, so that 
all parts exposed to outside contamination during the injury may be 
subjected to the irrigating fluids. For the irrigation of accidental 
wounds, corrosive sublimate (1: 10,000), carbolic acid (j4 per cent.), 
or formalin (1:300) may be used ; all of these solutions will delay 
healing to a certain extent, and are to be followed by salt-solution 
or boiled-water irrigation to remove the antiseptic. While irriga- 
tion is being carried out the wound must be thoroughly explored 
with forceps or director, and any gross foreign bodies, like bits of 
cloth or gravel, are to be removed. Irrigation of from five to ten 
minutes will generally be sufficient to insure clean healing in acci- 
dent cases when performed within an hour or two of the injury. 

Necrotic Tissue. — Tissues which have undergone such a degree 
of bruising or so great a loss of blood-supply as to give no prom- 
ise of surviving the injury, must be sacrificed in the interests of 
the patient. Sepsis is greatly favored by the presence of necrotic 
tissue, and only with absolutely certain asepsis can doubtful tissues 
be allowed to remain in the wound. Bruising of tissues is not 
confined to accidental wounds, but occurs in many operations 
where it might be avoided by the surgeon by a more rigid adher- 
ence to the proper principles of wound-treatment. The cuts of the 
knife should be made clean and straight. Blunt instruments and 
fingers should be used as little as is compatible with safety, and 
two cuts should never be made where one would have been 
sufficient. Buried stitches should be tied only tight enough to 
serve the purpose of approximation of the parts; and it should be 
remembered that the swelling which follows every operation will 
tighten a loose stitch, and perhaps cause a strangulation-necrosis in 
a tight one. In the choice between absorbable material and silk 
for ligatures and sutures, much must be left to the personal taste 
and experience of the operator. Silk is known to be absorbed in 
the course of time; but where germs are present in sufficient quan- 
tities to set up suppuration this absorption does not occur in time to 
prevent the opening of the wound and the discharge of the ligature. 
On the other hand, silk is a less favorable culture-medium for bacteria, 
and a smaller strand will give the necessary strength. Silk may 
be sterilized easily at the time of operation, while animal sutures 
require more elaborate preparation. The length of time during 
which an animal suture may be depended upon varies within wide 
limits. Cases are reported, on the one hand, where catgut ties gave 
way and allowed fatal hemorrhage from the uterine artery on the 
eighth day; and, on the other, chromicized catgut sutures have been 
removed intact from a hernia-wound four years after the operation. 

The use of animal sutures in the service of some of the sur- 
geons of the Massachusetts General Hospital is as follows : 

1. In cases of undoubted sepsis catgut is used for deep stitches 
and ligatures, except where large arteries require ligature. 

2. In cases of undoubted asepsis silk is used throughout. 

3. In skin-sutures silkworm-gut is used almost exclusively, 
either interrupted or continuous or subcutaneous. 



810 SURGICAL PATHOLOGY AND THERAPEUTICS. 

4. For sutures in mucous membranes, as the mouth or the 
vagina, catgut is used to avoid the necessity of removal. 

Dryness of Wounds. — Fluids collected in a wound force the sur- 
faces apart and delay or prevent healing in proportion to the 
amount of fluid present in any given case. The secretion of a 
clean wound has been found to possess a certain germicidal power 
for the first twenty-four to forty-eight hours ; but this power is not 
sufficient to protect the individual from the inoculation of any 
large number of bacteria, and after forty-eight hours the wound- 
secretion becomes a most favorable culture-medium for bacterial 
growth. For these reasons, oozing of blood, as well as more active 
hemorrhage, must be controlled by pressure of dry gauze sponges, 
preceded if necessary by a douching with salt-solution at 118 F. 
Active hemorrhage must be controlled, of course, by pressure- 
forceps; but care must be used to pick up only the bleeding point 
itself, and to save the surrounding tissues as much as possible from 
laceration. Blood-vessels which are not occluded by the temporary 
use of pressure-forceps will need ligature; but in each case the 
finest strand of ligature-material must be used which will bear the 
strain, in order that the amount of foreign material left in the 
wound may be reduced as much as possible. The application of 
pressure after closure of the wound contributes also to the pre- 
vention of hemorrhage and serous oozing. 

When copious oozing of blood or serum is unavoidable, as in 
wounds of large extent and in parts that are especially vascular, or 
where, as in thyroidectomy, pressure cannot be safely applied, some 
form of drainage is indicated to allow the escape of fluids. The 
materials used for drainage are tubes of glass or rubber, strands of 
gauze and wicking, and solid material like silkworm-gut. The 
tubes are rarely needed in clean cases; a small piece of gauze, folded 
in such a way as to prevent the ravelled edges remaining in the 
wound, or a bit of wicking will be sufficient to carry off the excess 
of fluid into the outer dressing. In many cases this wick may be 
removed at the end of twenty-four hours, and the skin closed at the 
point of exit by a " provisional " suture placed at the time of opera- 
tion, but left untied at the time w r ith this end in view. In this 
manner the advantages of drainage may be obtained without the 
sacrifice of primary healing. 

Where doubt exists with regard to the cleanliness of a wound, 
or when a wound opens an abscess-cavity or is undoubtedly septic, 
drainage becomes a matter of more than temporary expediency, 
and drainage-material must be adopted suitable to the amount and 
character of the discharge. Here tubes of glass or rubber are of 
decided advantage, and a system of double tubing which will allow 
of frequent flushing out with some antiseptic fluid is often much to 
be recommended. Rubber tubing, after a thorough washing in 
soap and water, may be sterilized by boiling for ten minutes, and 
kept for use in a 5 per cent, carbolic acid solution. Glass tubes 
can be boiled with the instruments, and are particularly valuable 
for deep abdominal drainage in that they are not collapsible. 
When used in this way, however, the glass tube should be sur- 



TREATMENT OF WOUNDS. 811 

rounded by several layers of gauze, to prevent erosion of the intes- 
tines. An efficient adjunct to the use of drainage-tubes in 
abdominal cases is a small glass syringe and a rubber catheter, 
with which the nurse can at frequent intervals suck out the fluids 
which collect in the lower portion of the tube. 

Closing the Wound. — All the cut surfaces in a wound must be 
brought together in such a way as to leave as small a space for the 
collection of wound-secretion as is possible. This end is best 
attained by a well-directed application of pressure in the final 
dressing, but can be materially aided in certain cases by the careful 
placing and gentle tieing of a few buried sutures. The skin-surfaces 
must be approximated, and many methods of suture are to be 
recommended — interrupted sutures, continuous, and subcutaneous. 
The special point to be emphasized, however, is this: That the 
part of the wound which is most doubtful in the matter of asepsis 
is the deeper layer of epidermal cells, and for this reason the suture, 
like the double-header (where two needles are threaded upon one 
piece) which is passed from within out, is always to be preferred to 
that which is passed from without in; and the subcutaneous stitch, 
which does not enter the epidermis at all, is a greater safeguard 
even than the "double-header." Whichever method of suture is 
adopted, only as many stitches should be placed as are essential to 
approximation; and none must be tied so tightly as to endanger 
the vitality of the tissue either by tension or by strangulation. 

Dressings. — The materials used for surgical dressings have 
been simplified in the last few years to such a degree that in clean 
wounds, at any rate, dry sterile gauze is almost universally pre- 
ferred. The dressing is intended to protect the wound and to absorb 
the discharges. Dry gauze is sufficient for both purposes; but when 
soaked through with blood and serum must be immediately re- 
placed by fresh sterile gauze, to avoid the contamination that will 
result from the ready migration of the bacteria from the outside 
through the serum-soaked meshes to the wound. Septic wounds 
with a large amount of discharge require frequent renewals of the 
dressing, to prevent decomposition of the discharges ; and for 
this end the antiseptic poultice is devised. Weak hot solutions of 
corrosive sublimate (i : 8000) or sulpho-naphtol (,5J to Oij) are pre- 
pared every four hours; and a gauze pad wrung out in this solution 
is applied, and covered with paper or oiled silk, to prevent evapora- 
tion. In septic conditions of the arm or foot, a bath of the same 
proportions may be substituted for the poultice, and the part remain 
immersed for one hour in every four, with beneficial effect. An- 
other variation of this use of antiseptic solutions is the constant- 
drip apparatus, by which a continuous stream of one of these 
weaker solutions is made to flow over or through a wound for 
hours at a time. 

Immobility. — Rest is one of the greatest factors in repair, and a 
proper restriction of the motions of the part affected is one of the 
greatest desiderata in wound-treatment. The limb must be placed 
in a comfortable position, so as to relax the tissues to the utmost; 
and it must be kept in this position by splints and bandages until 



8l2 SURGICAL PATHOLOGY AND THERAPEUTICS. 

healing is so far progressed as to preclude the possibility of sudden 
muscular action pulling the surfaces apart. With the painstaking 
observance of these principles, the surgeon has done all in the way 
of operative procedure that can be done to promote the healing of 
a wound, and the actual process of repair may thereafter be safely 
entrusted to Nature. 



III. BACTERIOLOGY OF THE MOUTH AND PHARYNX, EYE, 

EAR, AND NOSE. 

THE MOUTH AND PHARYNX. 

The mouth and pharynx possess conditions which are admir- 
ably adapted to the development of micro-organisms — namely, 
warmth, moisture, and an abundance of nutrient material. The 
exposed situation of these cavities favors the continual introduc- 
tion of bacteria in air, food, and a variety of foreign substances. 
While most of the species occurring are saprophytic, yet a few 
pathogenic ones may usually be found in healthy individuals, and 
under certain circumstances may multiply to a considerable extent 
without producing any discoverable local or general disturbance. 

Bacterial invasion of the tissues of the mouth and pharynx is 
largely restricted by the following agencies : i. The character of 
the mucous membrane ; 2. The action of ingested food and secreted 
fluids ; 3. Phagocytosis. 

1. The mucous membrane is of the pavement-form, in most 
places compact and well nourished by an abundant blood-supply. 
Epithelial regeneration and desquamation are rapid and contin- 
uous. In the mucous membrane covering the tonsils and lymph- 
oid structures of the pharynx, however, a looser texture exists, 
with actual deficiencies and channels communicating with the 
efferent lymph-vessels. Such places, although protected to a cer- 
tain extent by the active phagocytosis there present, nevertheless 
constitute frequent entrance-points of bacterial infection. 

2. The ingestion of food and fluids flushes the mouth and throat 
periodically and removes large numbers of micro-organisms. With 
regard to the action of saliva, recent investigations have shown 
that, while it does not markedly influence the vegetative activities 
of most bacteria, it distinctly lessens the virulence of pathogenic 
forms. This diminution in virulence exists, however, only so 
long as the micro-organisms are in contact with the saliva, and 
may be restored by cultivating them upon other culture-media. 

3. Phagocytosis in the mouth probably does not play a conspic- 
uous part in controlling the activities of micro-organisms. In the 
crypts of the tonsils, however, the polynuclear leukocytes are an 
important barrier against infection, and compensate more or less 
completely for the loose epithelium and imperfect drainage there 
present. 



BACTERIOLOGY OF THE MOUTH AND PHARYNX. 813 

From the surgical standpoint, the occurrence of pathogenic 
bacteria in the mouth and pharynx offers two important subjects 
for consideration : First, the possible transportation of such germs 
to vulnerable parts of the body during operative procedures; sec- 
ond, the effect of their presence upon wounds of the oral and pha- 
ryngeal tissues. 

With regard to the first possibility, the inhalation of bacteria 
from the mouth immediately suggests itself as the cause of pneu- 
monia following etherization. It has been shown that during 
forcible inspiration particles of mucus or saliva may be drawn into 
the bronchi and bronchioles, whence they are driven, by the air- 
pressure during the succeeding act of coughing, into the alveoli. 
In this manner, pathogenic bacteria may be carried, suspended in 
particles of fluid, into the lung-tissue. This mode of origin ap- 
pears more probable than that the pneumonia is caused by the 
inhalation of pathogenic germs from the surrounding air, inas- 
much as the latter contains an insignificant number in comparison 
with those present in the mouth. It thus would seem to be of 
practical importance to sterilize, as far as possible, the mouths of 
patients previous to etherization (see below for formulas). 

The Surgical Preparation of the Mouth for Operation. — 
While the use of antiseptic washes has been shown to destroy bac- 
teria in the saliva or on the exposed surface of the mucous mem- 
brane, it is not likely to affect germs situated in the cavities of 
carious teeth, unless a mechanical cleansing be also performed. 
The routine followed at the Massachusetts General Hospital, sug- 
gested by W. F. Whitney, is to be recommended as calculated to 
minimize the danger from inhalation-pneumonia : Several days 
before the operation the patient's teeth are examined by a dentist 
and thoroughly cleansed. Any cavities present are filled. Me- 
chanical cleansing and sterilizing are continued by rinsing the 
mouth and brushing the teeth, especially about the roots, several 
times a day with an antiseptic solution. The pharynx and tonsils 
are sprayed at the same time with the antiseptic. As shown in the 
section on the Bacteriology of the Nose, sterilization of the nasal 
passages is superfluous, with the exception of the vestibule, which 
contains great numbers of bacteria, and will tolerate vigorous anti- 
septic measures without injury. It is well to adopt this prepara- 
tion in all cases in which anaesthesia is to be produced, and espe- 
cially in all cases of operations upon the mouth or the abdomen, 
in order to avoid the dangers of a septic pneumonia. 

Notwithstanding the abundance of micro-organisms in the 
mouth and pharynx, wounds and injuries of these parts ordi- 
narily heal with rapidity, a result due to the great vascularity 
of the tissues and to the continual flushing and free drainage. 
Asepsis is practically impossible to secure, and the entrance of 
new organisms into the mouth and pharynx cannot be prevented. 
Strong antiseptic solutions, especially salts of mercury, inhibit the 
normal processes of regeneration in wounded tissues, and may 
even cause a breaking down of previously healthy structures in 
the vicinity. 



814 SURGICAL PATHOLOGY AND THERAPEUTICS. 

The subject of mouth-sterilization has been most fully investi- 
gated by Miller, who has shown that many of the agents ordinarily 
relied upon for this purpose are of little or no value. Among the 
preparations which show but slight power to disinfect the mouth 
are potassium chlorate, borax, and carbolic acid. The value of 
these and similar remedies probably lies chiefly in the mechan- 
ical acts of flushing and cleansing during their use. Of the anti- 
septics which may be used daily without injury to the teeth, sac- 
charine and benzoic acid were shown to be the most efficient. The 
following formulae are recommended : 

R. Acid, benzoic, 3. 

Tinct. eucalypt., 15. 

Alcohol., 100. 

01. menth. pip., 0.75. — M. 

Sig. — To half a wineglassful of water add enough of 
the solution to produce distinct clouding. Hold in 
the mouth for one minute. 

The antiseptic strength of the mixture is increased by the addi- 
tion of 0.8 gram of corrosive sublimate, although this is not to be 
recommended for daily use. 

R. Saccharini, 2.5 

Acid, benzoic, 3. 

Tinct. ratanh., 15. 

Alcohol, absol., 100. 

01. menth. pip., 0.5. 

01. cinnam., 0.5. — M. 

Sig. — Dilute with ten parts of water, or, better, ten 
parts of a 4 per cent, solution of hydrogen peroxide, 
and hold in the mouth for one minute. 

These preparations have been shown to exert a powerful bac- 
tericidal effect without apparent injury to the teeth or the soft 
tissues. It should, however, be emphasized that their use is not 
indicated in clean wounds with good drainage, as epithelial regen- 
eration is likely to be more retarded than if a simple cleansing 
wash were employed. 

Formalin is a powerful disinfectant, about equal in germicidal 
action to corrosive sublimate. Its irritating effect renders it unsuit- 
able for use upon mucous membranes, except in solutions of y 2 
per cent, or less. In combination with various neutral salts and 
essential oils, it enters into the composition of several recent 
proprietary solutions, and is probably the chief factor in the 
antiseptic efficacy of such preparations. 

Pathogenic Bacteria of the Mouth. — Streptococcus Pyo- 
genes. — This organism is found in catarrhal and ulcerative 
stomatitis, in parenchymatous inflammations, especially of the 
tongue, in acute inflammation of the lingual and faucial tonsils, 
and in most suppurative processes. It is generally associated with 
other pyogenic bacteria, especially forms of staphylococci. 



BACTERIOLOGY OF THE MOUTH AND PHARYNX. 815 

Staphylococcus Pyogenes Albus, and the varieties Aureus and 
Citrcus. — These organisms are the etiological factors in many 
acute inflammations of the mouth and pharynx, such as aphthous 
stomatitis, acute lingual and faucial tonsillitis, and in most suppu- 
rative processes, occurring either alone or in association with the 
Streptococcus pyogenes. 

Klebs-Loffler bacillus gives rise occasionally in the mouth to a 
fibrinous inflammation, which may either be isolated or occur in 
association with diphtheria of the fauces. 

Pneiunococcus of Frdnkel. — This organism occurs normally in 
the mouth and on the surface of the tonsil. It gives rise rarely to 
a tonsillitis characterized by sudden onset, the presence of a false 
membrane, and termination of fever by crisis. 

Bacillus of Friedlander. — This bacillus has been found in cases 
of tonsillitis running a subacute or chronic course, and has been 
held by some observers to be the etiological factor. 

Bacillus of Tuberculosis. — This bacillus may invade the tissues 
of the mouth and pharynx, either primarily or secondarily, in the 
course of pulmonary tuberculosis. The lesions may be miliary in 
character at the beginning, forming later superficial ulcerations; 
or they may take the form of nodular swellings. The lupous form 
is generally an extension from lesions of the adjacent skin. 

Bacillus of Lepj'osy. — This bacillus at times produces lesions of 
the mouth during the course of the general disease. 

Bacillus of Glanders. — This organism frequently invades the 
tissues of the mouth and pharynx in persons suffering from the 
general affection. The lesions of the mucous membrane are 
analogous to those on the skin, occurring as circumscribed infil- 
trations and losses of substance. 

Bacillus of Typhoid Fever. — This bacillus has been found in 
the mouths of patients suffering from the general disease, and is 
supposed to be the cause of the superficial ulcerations sometimes 
found on the anterior pillars of the fauces. 

Among other micro-organisms, may be mentioned the ray-fungus 
(the cause of actinomycosis) and Saccharomyces albicans (the cause 
of thrush). 

Caries of the teeth is due to the action of several acid-forming 
species of bacteria, and not to a single specific organism. The 
acids are excreted by the bacteria in situ on the surface of the 
teeth. According to J. L. Williams, at least two-thirds of the 
dental decay now prevalent may be prevented by the faithful use 
of germicides. For this purpose, the milder form of the two anti- 
septic mouth-washes previously given (page 814) may be used with 
regularity daily. 

The Antiseptics of Tooth-filling. — Complete sterilization 
of a cavity requires, as shown by Miller's experiments, a consider- 
ably longer time than has ordinarily been supposed. In many 
cases it is advisable to allow the antiseptic to remain in the cavity 
for half an hour, or even for twenty-four hours. This is best done 
by applying the antiseptic on a small pledget of cotton, and closing 
the cavity with soft cement or other protective material. After 



816 SURGICAL PATHOLOGY AND THERAPEUTICS. 

removal of the antiseptic, and immediately before introducing the 
filling, a current of hot air is to be blown into the cavity. This 
has been shown to diminish very considerably the chance of any 
germs persisting in the walls of the cavity. 

Of the various antiseptics used to sterilize cavities, carbolic acid 
is most generally employed. Styrone, trikresol, and lysol are also 
efficient disinfectants. These are all used pure. Where a bleach- 
ing of the tooth is desired in addition to a powerful germicidal 
action, pyrozone in ethereal solution is to be considered a most 
useful preparation. The weaker solutions are to be used only 
where all caries has been removed, as their penetrating powers 
cannot be relied upon. 

Proper cutting and polishing of the enamel-margins of cavities, 
and the absolute sealing of them, are matters of as great importance 
as sterilization, since upon them depends the prevention of subse- 
quent penetration of micro-organisms. 

Diagnosis of Acute Infectious Inflammations of the 
Throat. — In acute exudations of the upper air-passages the neces- 
sity for accuracy in diagnosis has been emphasized by the intro- 
duction of serum-therapy. Whether the inflammatory phenomena 
are excited by pyogenic bacteria or by diphtheria-bacilli is a matter 
of the gravest import to prognosis and treatment. In a large 
percentage of cases such a knowledge can be attained by applying 
the bacteriological test. Within the space of twenty-four hours 
cultures from the affected mucous membranes suffice to establish 
the diagnosis with a precision unattainable by clinical methods. 
Where culture-tubes of serum are not procurable, or are so seldom 
employed as to be likely to dry out, the culture may be conveni- 
ently taken on the sterilized swab shown in Fig. 81, and thus 
transmitted to the bacteriological laboratory for inoculation. 

In taking a culture from the throat, care should be taken to press 
and twist the cotton of the swab rather firmly against the affected 
surface, as diphtheria-bacilli are frequently more deeply situated in 
the false membrane than are pus-cocci, and consequently are more 
likely to escape removal. For practical purposes, at the present 
time we have to consider, in a doubtful case of pharyngitis or 
tonsillitis, only the diphtheria-bacillus, the Streptococcus pyogenes, 
and the Staphylococcus albus and aureus as the possible causative 
factors. In a very few cases the pneumococcus was found to be the 
cause of an exudative tonsillitis, while occasionally Friedlander's 
bacillus and the Micrococcus tetragenus were apparently the 
infecting agents. Such conditions deserve further investigation. 

THE EYE. 

The normal conjunctiva contains always large numbers of 
micro-organisms. While most of these are being constantly 
drained away by the tears, a certain number persist in the sac, 
owing to their deep situation under the epithelium, or in the ducts 
of the glands. They are, furthermore, especially abundant in the 
lid-borders and the roots of the lashes. A germicidal action has 



BACTERIOLOGY OF THE EYE. 817 

been attributed to the tears; but this property, if present, is 
exercised only against certain bacteria, not toward all. Bacteria 
are not, as a rule, found in the secretion of perfectly normal 
glands (Gifford). 

Owing to the fact that many bacteria are so deeply seated, it is 
impossible to sterilize the conjunctiva completely, even over limited 
areas; while it is even more difficult to remove the germs from the 
lid-borders and the roots of the lashes. In preparing for opera- 
tions and in the treatment of wounds, antiseptics should be avoided, 
as they are likely to injure the delicate structures, especially the 
cornea, as well as to inhibit the processes of repair. Douches of 
normal salt-solution and mechanical cleansing before operations are, 
however, eminently desirable. Observance of the following details 
is recommended: The face and lids are washed with soap and warm 
water prior to the operation. The conjunctival sacs and surfaces 
are washed with sterilized normal salt-solution. A moderately firm 
wiping of the lids and lashes has been shown to diminish very 
considerably the number of bacteria present in these situations. 
During the operation everything that touches the eye is to be 
aseptic, but no antiseptics are allowed to come into contact with 
it. After the operation the eye is gently douched with salt-solu- 
tion. The dressing consists of moist linen and one or two layers of 
absorbent cotton, kept in position by horizontal and vertical plaster 
strips. The aim before, during, and after the operation is to keep 
the conjunctiva as nearly as possible in its normal condition and 
free from irritation. 

Sterilization of the more delicate instruments must be performed 
with great care, to avoid injuring their edges. The edge of the 
instrument should first be examined with a magnifying-glass, to see 
that it is in proper condition; then the instrument is wrapped in 
cotton and placed in the boiling soda-solution. From this it is 
placed in absolute alcohol until ready to use, when the blade is 
freed from the alcohol by dipping into sterilized water. 

Sterilization of small instruments by the vapor of formaldehyde 
is now generally practised, and is most conveniently done in one 
of the special sterilizers now for sale. 

A classification of conjunctivitis, depending upon the demon- 
strated presence of certain microbes, has been proposed ; but any 
such attempt can only lead to error in the present state of our 
knowledge, since there may be cultivated from the discharge 
certain germs which have no influence in causing the disease ; 
thus, one dare not say, in the absence of membrane upon the con- 
junctiva, that diphtheria is present merely because one has suc- 
ceeded in demonstrating the diphtheria-bacillus in the exudation. 
Nor must it be forgotten that two infections may be present at one 
time, as when we infect a patient suffering from trachoma with 
gonorrhceal ophthalmia (Morax and R. Petit). 

At least ten species of bacteria have been isolated from the 
normal conjunctiva. Although most of them are not ordinarily 
pathogenic, they may become harmful if the tissues in which they 
exist become bruised or irritated (Randolph).. 

52 



818 SURGICAL PATHOLOGY AND THERAPEUTICS. 

The pathogenic micro-organisms which occur also under condi- 
tions of health are the Staphylococcus pyogenes albus and aureus, 
and the xerosis bacillus. 

Staphylococcus Pyogenes Albus and Aureus. — These occur nor- 
mally in greatest abundance along the lid-borders and in the roots 
of the lashes. Pathologically, they are found in many inflamma- 
tions, such as blepharitis, phlyctenular conjunctivitis, in ulcera- 
tions of the cornea that are not typically serpiginous, in suppu- 
rative conditions; and in association with other specific inflamma- 
tions, such as diphtheritic and gonorrhoeal conjunctivitis. 

Xerosis Bacillus. — This micro-organism resembles closely the 
bacillus of diphtheria; but it is not virulent for animals. It occurs 
normally in the conjunctiva; and is also found in inflammations, 
especially in association with the Koch-Weeks bacillus. 

The following bacteria are not found normally in the eye, and 
their presence is usually attended by pathological alterations in 
the tissues : 

Koch-Weeks Bacillus. — This bacillus resembles closely the bacil- 
lus of mouse-septicaemia; and measures i to 2 mm. in length, and 
0.25 mm. in thickness. It is found in the conjunctival sac as the 
etiological factor in acute contagious conjunctivitis. 

Diplobacillus of Morax and Axenfeld. — This occurs in the form 
of a diplobacillus, each member of which measures 2 to 3 mm. in 
length, and 1 to 0.5 mm. in breadth. Chains of these diplobacilli 
are not infrequent with no apparent sign of division. It is decol- 
orized by Gram's method. It causes a subacute or chronic con- 
junctivitis, running a course of from six weeks to six months. 

Pneumococcus of Frdnkel. — This organism may give rise to an 
acute contagious inflammation of the conjunctiva, closely resem- 
bling, clinically, the conjunctivitis produced by the Koch-Weeks 
bacillus. It is one of the etiological factors in typical serpiginous 
ulceration of the cornea, where it may at times be found in almost 
pure culture. It is also one of the causes of panophthalmitis. 
Kyle found that in Matanzas, during the Spanish War, the great 
majority of cases of conjunctivitis that occurred were due to this 
organism. 

Streptococcus Pyogejzes. — This organism is found in many sup- 
purative inflammations and in certain forms of corneal ulceration. 
It may also give rise to membranous conjunctivitis. 

Gonococcus of Neisser. — This organism is an etiological factor 
in gonorrhoeal conjunctivitis and in severe cases of conjunctivitis 
neonatorum. 

Klebs-Lbffler Bacillus. — This bacillus is the cause of diph- 
theritic conjunctivitis. It develops on the conjunctiva, however, 
only when the mucous membrane is in a condition to receive it, 
such as might be brought about by an antecedent simple con- 
junctivitis or general depressing illness. 

Bacillus of Tuberculosis. — This bacillus produces characteristic 
tuberculous lesions in the ocular coats. 

Bacillus of Leprosy. — This organism, at times, invades the eye, 
and gives rise to characteristic nodules. 



BACTERIOLOGY OF THE EAR. 819 

Other micro-organisms have been cultivated from infectious 
diseases of the eye, such as trachoma ; but their etiological rela- 
tionship has not yet been demonstrated. 

THE EAR. 

The external ear forms, so far as its bacteriological relations are 
concerned, simply a portion of the cutaneous covering of the body, 
and does not require special consideration. The most frequent 
bacterial affection is furunculosis of the external meatus, caused 
by staphylococci, generally the Staphylococcus pyogenes aureus. 

Invasion of the middle ear by bacteria occurs most frequently 
from the nasopharynx through the Eustachian tube. The latter 
is lined with ciliated epithelium, the motion of which is directed 
from the tympanum toward the pharynx, thus constituting, under 
normal conditions, an effective barrier against the entrance of 
micro-organisms. When, through accident (such as too forcible 
blowing of the nose) or through disease of the tubal epithelium, 
germs enter the middle ear, they may remain there without harm 
and lose their virulence, or they may be thrown out again. If 
external influences (as chill or trauma) depress the vitality of the 
mucous membrane of the tympanum through impairment of its 
nutrition, then favorable conditions for the growth and develop- 
ment of micro-organisms appear to be provided, and a reactive 
inflammation results. 

Less frequent avenues of infection of the middle ear are through 
the blood-vessels in endocarditis and in general septic conditions, 
through the dural process in the petrosquamosal suture, and 
through the drum-membrane if the latter be wounded or perfo- 
rated. 

Sterilization of the external meatus and drum-membrane, prior 
to opening the tympanic cavity, should be done by gentle irriga- 
tion with a warm solution of mercuric chloride of the strength of 
1 : 5000; followed by instillation of alcohol, which is then removed 
by pledgets of sterilized absorbent cotton. 

In irrigation of the exposed middle ear, the same practice should 
be followed as in the case of other delicate mucous membranes — 
namely, to cleanse without irritation. In the absence of second- 
ary infection, sterilized normal salt-solution fulfils all requirements. 
Where a moderate degree of antiseptic action is desirable, mercuric 
chloride in 1 : 5000 solution or saturated boric-acid solution may 
be used. In chronic suppurations, with accumulation of foul pus, 
peroxide of hydrogen is very useful, and may be injected, a few 
drops at a time, through a slender glass pipette into the middle 
ear. This not onlyiexerts a germicidal action directly, but also 
disintegrates the masses of epithelium and cheesy pus, so that 
their subsequent removal is greatly facilitated. These instillations 
may be repeated several times at each sitting until no more effer- 
vescence takes place. 

Antiseptic powders find their place in chronic infections of the 
middle ear, where a prolonged mild germicidal action is desired. 



820 SURGICAL PATHOLOGY AND THERAPEUTICS. 

Among these may be mentioned boric acid, europhen, aristol, 
nosophen, and iodoform. 

Alcohol is an excellent antiseptic, and is well tolerated in most 
chronic middle-ear suppurations, especially if exuberant gran- 
ulations are present. At the beginning, it should not be used 
stronger than 70 per cent. ; but later this may be increased to 95 
per cent. 

Solutions of nitrate of silver are often very useful in suppura- 
tive conditions, especially when the mucous membrane is relaxed 
and flabby, both from its antiseptic action and from its power of 
constricting the blood-vessels. It may be injected into the middle 
ear in strengths of from o. 5 per cent, to 1 per cent. 

The sterilization of instruments should be performed according 
to general surgical principles. In the case of hard-rubber catheters 
and other instruments, which cannot be boiled, the formaldehyde 
sterilizer may be used to advantage. 

Acute infectious inflammations of the middle ear are most 
commonly due to the pneumococcus of Frankel and the Strepto- 
coccus pyogenes, less frequently to the Staphylococcus pyogenes 
albus and aureus. Occasionally the bacillus of Friedlander, 
Pfeiffer's bacillus of influenza, and the Bacillus pyocyaneus are 
causative factors. The clinical phenomena excited by these micro- 
organisms vary chiefly as regards their severity, the complications 
of greatest gravity occurring in infections with the bacillus of 
Friedlander and the Streptococcus pyogenes. The latter organism 
is the principal one found in inflammation of the internal ear. 

At the beginning of the inflammation, previous to perforation 
of the drum-membrane, there is generally but one species of micro- 
organism present. After perforation, secondary inoculation of the 
tympanic cavity with pyogenic and saprophytic germs often occurs, 
which crowd out the original species. 

Infections of the middle ear occurring in scarlet fever, diph- 
theria, typhoid fever, measles, and mumps show the presence of 
pus-cocci, generally the Streptococcus pyogenes. 

In tuberculosis of the lungs and other organs an involvement 
of the middle ear may occur, characterized by chronic suppuration 
and caries of the bony structure. 

THE NOSE. 

The number of bacteria entering the nose with the inspired 
current of air varies naturally within wide limits. In ordinary 
city-air the number reaches several thousand per hour. Where 
the nasal vestibule is provided with vibrissas, these serve to retain 
a large proportion of the micro-organisms. As may be shown 
experimentally, the incoming stream of air, with its suspended 
dust and bacteria, after passing the vibrissas, is deflected by the 
constricting band of the vestibule against the septum at about 
the middle of its cartilaginous portion. From this point the cur- 
rent is again turned upward and outward, against the anterior 
end of the middle turbinate. The bacteria which still remain 



BACTERIOLOGY OF THE NOSE. 821 

suspended in the air are almost wholly filtered out in their subse- 
quent passage through the nasal chambers and the nasopharynx, 
with the result that nasally inspired air is normally free from micro- 
organisms when it reaches the larynx and trachea. 

Although bacteria are thus constantly being deposited in great 
numbers upon the nasal mucous membranes, under ordinary condi- 
tions they not only fail to develop there, but they are removed with 
great rapidity. Cultures of known bacteria spread experimentally 
upon the nasal mucosa, begin to disappear within a few minutes, 
and after two hours cannot be recovered. The agencies which 
contribute to this disposal of bacteria are: 1. The action of the 
ciliated epithelium. 2. The drainage downward of fluid from the 
upper portions of the nasal chambers. 3. The composition of the 
nasal mucus, which is unfavorable for the growth of micro- 
organisms, although destructive to only a few pathogenic ones — i. e. 
anthrax-bacilli. Polynuclear neutrophilic leukocytes are found in 
considerable numbers upon the nasal mucous membrane, but the 
extent of their phagocytic action is probably limited. Where, 
however, the lymphoid tissue of the nasopharynx is present in 
considerable amount, as in children, phagocytosis is a conspicuous 
factor in disposing of micro-organisms. 

In view of the efficiency of these natural agencies which repel 
bacterial invasion, it is evident that artificial sterilization of the 
nasal mucous membrane is superfluous. Furthermore, chemical 
substances capable of destroying bacteria are likely also to affect 
unfavorably the delicate tissues within the nose, by inhibiting the 
customary rapidity of epithelial regeneration, or by checking 
ciliary action, or by altering the character of the nasal secretions. 
Sterilization of the skin and hairs of the vestibule previous to 
intranasal operations is, on the other hand, eminently desirable, 
in order to destroy, so far as possible, the immense numbers of 
bacteria situated in this region, which might otherwise be carried 
into the nose upon the fingers and upon instruments. While it is 
doubtless impossible to sterilize the skin of the vestibule com- 
pletely — for instance, at the roots of the hairs — yet, as shown by 
experience in other localities, as in the conjunctiva, removal of the 
greater portion of the bacteria may contribute materially to the 
success of operations. The hairs and the skin should first be freed 
mechanically from germs, as far as possible, by firm wiping, after 
which a pledget of absorbent cotton wet with corrosive-sublimate 
(1 : 1000) solution, but not dripping, should be left for several 
minutes in the vestibule. 

The after-treatment of wounds within the nose consists essen- 
tially in filtering out the germs of the inspired air, in keeping the 
nasal discharges moist, and in aiding free drainage. These results 
are best secured by the following measures: After the operation, 
if hemorrhage has ceased, an antiseptic powder — nosophen or 
aristol — is dusted upon the cut surface, and a loose pledget of cotton 
placed in the nostril. After a few hours the wound is covered by 
a false membrane, composed of fibrin and leukocytes, beneath which 
granulations form and epithelial regeneration takes place. This is 



822 SURGICAL PATHOLOGY AND THERAPEUTICS. 

the normal method of healing, and it is only necessary to see that 
no irritating bacterial process takes place beneath the false mem- 
brane. Mucus is apt to dry over the surface of the exudate, 
preventing free drainage. Such crusts should be softened by 
spraying with some bland alkaline watery fluid, and removed with 
nasal forceps. Antiseptic solutions should be avoided after opera- 
tions within the nose, with the exception of peroxide of hydro- 
gen, which is useful at times for its power of disintegrating and 
softening the discharges, thereby aiding in free drainage. 

Pathogenic Bacteria of the Nose. — Streptococcus Pyogenes 
and Staphylococcus Pyogenes Aureus and Aldus. — These micro- 
organisms may occur either singly or in association, in acute and 
chronic catarrhal processes, in suppurations such as septal abscess, 
and as a complication with other specific inflammations, especially 
diphtheria. 

Klebs-L&ffler Bacillus, or the Bacillus Diphtherias . — This 
organism at times produces an inflammation of the nasal mucous 
membrane, either isolated or in connection with faucial diphtheria. 

Other infections of the nose, generally of a chronic character, 
occur from inoculation with the tubercle-bacillus, the bacillus of 
glanders, the leprosy-bacillus, and the bacillus of rhinoscleroma. 
In atrophic rhinitis many organisms occur in the nose, without, 
however, playing any other role than that of saprophytes. 



IV. BACTERIOLOGY OF THE GENITOURINARY SYSTEM. 

An understanding of the bacteria that are present normally or 
in disease in some portion of the genito-urinary tract is essential; 
for without such knowledge the etiology is obscure, the diagnosis 
incomplete, the prognosis valueless, and not only may the treat- 
ment be inappropriate, but serious delay may follow. In general, 
without the presence of bacteria the genito-urinary system is free 
from inflammatory disorders; but their presence alone is not usually 
sufficient to cause disturbance. They act as the exciting cause; 
and they are able to multiply and do harm only in some region 
made less resistant and unable to withstand their pyogenic action 
by some predisposing cause, whether it be a direct trauma or a 
purely nutritive disturbance. 

For the reason that the bladder serves as a common reservoir 
for the urine, and communicates more or less directly, especially in 
the male, with all the genito-urinary organs, it is most convenient 
and satisfactory to study the effect of the presence of germs from 
this center. As a result of laboratory research and clinical obser- 
vation, certain principles would seem to be established : 

r. Like the cutaneous surface of the body, the external genitals 
are the habitat, even in health, of micro-organisms, but in far 
greater profusion. This will include the vulva and vagina in the 
female, the prepuce in the male, and the urethra in both sexes as 



BACTERIOLOGY OF THE GENITOURINARY SYSTEM. 823 

far as the constrictor urethral muscle. 2. Normal urine is sterile ; 
therefore, in health, the urinary tract above this u cut-off" muscle 
is free from bacteria. 3. Ligature of the urethra in health does 
not give rise to cystitis, but is followed by nutritive disturbances 
in the bladder-wall, thereby rendering this organ a locus minoris 
resistentue. 4. Pure cultures injected into a healthy bladder are 
soon voided with the urine, and do no harm ; the proteus Hauser, 
however, is an exception to this general statement, for reasons to 
be described later. 5. Pure cultures of pyogenic bacteria injected 
into a bladder whose vitality or power of resistance has been suf- 
ficiently diminished will give rise to a cystitis. Retention from 
any cause is a powerful factor in lowering such vitality. 6. In 
health, ligature of a ureter is followed in due time by renal atrophy 
without suppuration, and usually unattended with serious disturb- 
ance. 7. It is doubtful whether a healthy kidney will allow the 
passage of bacteria from the circulation into the urine ; but if dis- 
eased, bacteria unquestionably pass through the tissue into the 
urine. 8. As in the bladder, suppuration in the kidney demands 
suitable conditions in addition to the presence of micro-organ- 
isms. 

Predisposing Conditions ; Role Played by Bacteria in the 
Causation of Cystitis. — Cystitis is an inflammatory process of 
varying severity in the bladder-wall, and is characterized by the 
presence of pus-corpuscles in addition to other cell-elements. 
Furthermore, no cystitis can arise without the presence of bacteria, 
which, in turn, demand a suitably prepared soil. A healthy mucous 
membrane does not offer a favorable nidus, and it is not unusual to 
observe a urine swarming with bacteria (notably Bacterium coli 
commune), and yet the bladder-wall remain intact and resist bac- 
terial invasion. Such a condition is known as " bacteriuria." 

The factors tending to lower the resistance of the bladder-wall 
are numerous. The age and general health of the patient are 
important considerations, for young and vigorous subjects possess 
correspondingly healthy and tonic bladder-walls, active in repair- 
ing injury, and able to void the urine without any residuum ; 
bacteria are rapidly expelled, even if accidentally introduced; and 
the nutrition of the part is sufficient to overcome the effect of ordi- 
nary trauma. In the aged, the bladder-walls are atonic and dis- 
tended, and often unable completely to void the urine. An en- 
larged prostate gland not uncommonly gives rise to retention, 
which is one of the most powerful factors in lowering the resist- 
ance of the wall to infection, so commonly introduced with the 
catheter. Such cases are particularly susceptible to infection, 
which not infrequently may extend to the kidney. Strictures of 
the urethra, with obstruction, act in a similar manner. Acute 
retention from any cause, and pressure on the bladder by pelvic 
tumors, also impair its nutrition. Trauma, whether it result from 
instrumentation or follow the constant irritation due to the pres- 
ence of foreign bodies, particularly calculi, is a potent factor in 
this connection. Chemical irritants (drugs and local applications), 
hyperacidity, alkalinity, venous stasis, and arterial congestion 



824 SURGICAL PATHOLOGY AND THERAPEUTICS. 

from chilling of the skin may interfere with the resisting power of 
the bladder-wall. 

Bacterial Invasion. — The presence of bacteria in the bladder 
is not sufficient cause to produce a cystitis (proteus Hauser ex- 
cepted), unless some nutritive disturbance has preceded their 
advent, or unless they remain long enough for such change to take 
place ; but nevertheless, their presence is an absolute necessity. 
When once the soil is predisposed, the resulting inflammations will 
vary according to the kind of infection, the number of micro- 
organisms, and the absence of mixed infection, as well as the con- 
dition of the bladder-wall and the urine. 

Cystitis is a suppurative process, hence the invading bacteria 
must be pyogenic ; and it would seem that the power to decom- 
pose urea possessed by many varieties is not sufficient per se to 
give rise to such an inflammatory process. These two powers, 
however, may be combined in a single variety of micro-organism. 
The varieties possessing only the power to decompose urea are 
commonly voided before they cause trouble, for fresh acid urine is 
constantly being excreted by the kidneys in sufficient quantity to 
overcome the alkaline tendency of the urine in the bladder, which 
is voided from time to time. If, on the other hand, retention 
should take place, then these micro-organisms multiply rapidly ; 
the urine becomes alkaline, thereby favoring the action of any 
pyogenic bacteria that may already be present or be introduced 
in the effort to relieve the retention. 

Bacteria which are purely pyogenic multiply in the urine, and 
under favorable conditions penetrate the bladder-wall and cause 
suppuration : and only bacteria with this characteristic, which 
may or may not be combined with the power to decompose urea, 
are able to cause a cystitis. Suppurative processes in the urinary 
tract, therefore, demand two conditions — the proper condition of 
the soil and the presence of pyogenic bacteria. 

Reaction of the Urine. — Given a cystitis consequent on the 
invasion of purely pyogenic bacteria, the urine will remain acid 
throughout its course. Some of these bacteria have a feeble power 
of decomposing urea ; but even then the urine ordinarily remains 
acid. Such forms of acid cystitis are the commoner, and also 
include the more serious types (Bacterium coli commune, tuber- 
cle-bacillus, Streptococcus pyogenes). 

If the invading bacteria are feeble decomposers of urea, the 
periodical evacuation of the bladder and the constant flow of acid 
urine from the kidneys are sufficient to maintain an acid urine ; 
but sudden retention of urine is sufficient to render it alkaline, and 
even ammoniacal, and thereby the pyogenic property is often en- 
hanced. For the above reason, simple decomposers of urea may 
be present for a long time without overcoming the normal acidity 
of the urine. 

An acid cystitis, therefore, may persist as such or become 
alkaline under the circumstances just cited; but, furthermore, it 
may become alkaline: (a) if the micro-organism decomposing urea 
is active (proteus Hauser, Staphylococcus ureae liquefaciens); (b) if 



BACTERIOLOGY OF THE GENITO-URINARY SYSTEM. 825 

the relation between the soil and the virulence of the micro- 
organism is altered (^alcoholism, excesses, violent exercise); or (c) if 
a purelv pyogenic variety becomes secondarily infected with decom- 
posers of urea. Drugs may influence the reaction of urine. It is not 
unusual for an alkaline cystitis to become acid on the removal of 
some of these causes — dilating strictures, use of catheter to prevent 
residual urine, rest, diet, local irrigations, and internal medication. 
Nevertheless, many a cystitis tends to persist when once thoroughly 
established. Ammoniacal decomposition is generally due to a 
mixed infection, and is of secondary importance; but of itself it is 
not a direct cause of cystitis, although such a condition enhances 
the activity of many pyogenic bacteria. 

Bacteria in the Vicinity of the Meatus Urinarius and in 
the Male Urethra. — Much confusion exists at present among 
authorities, both in regard to the varieties of micro-organisms 
associated with the genito-urinary organs in health and disease, 
and also in regard to the role they play. This confusion is readily 
understood when we consider the large number which frequent the 
external genitals in health, as well as the additional varieties 
associated with disease. Several varieties are usually present in 
every case, and it is a difficult task to isolate and cultivate them. 
Furthermore, polymorphism adds to the difficulty of isolation and 
identification. 

As has been stated, the external genitals as far as the constrictor 
urethral muscle are the habitat in health of many varieties of 
bacteria; but above this muscle the genito-urinary tract is sterile. 
Some of these bacteria are pathogenic; but the great majority, so 
far as known, do not give rise to trouble. Even the varieties which 
may give rise to a fatal cystitis or pyelonephritis may remain in 
the urethra for an indefinite period without causing trouble. The 
difficulty of rendering the urethra aseptic and the danger conse- 
quent on introducing instruments into the bladder will be con- 
sidered later. 

At least twenty varieties of micro-organisms have been obtained 
from the external genitals by different observers; but later research 
may show many of these to be one and the same variety. Many 
of them have the power to decompose urea, but comparatively few 
are pathogenic. There are many reasons for believing that the 
majority of these varieties may complicate cases of cystitis in 
which there has been much instrumentation, and that they play a 
decidedly secondary role, for examination of cases of cystitis fre- 
quently shows a pure culture of some pyogenic variety. 

The commoner bacteria found in the flora of the external 
genitals and urethra are merely enumerated in this connection; but 
the important ones will be considered in detail in connection with 
the flora of cystitis. 

Flora of Urethra and about the Meatus Urinarius and 
Vulva. — Bacterium coli commune; Coccobacillus liquefaciens 
urethrse; Bacillus urethrae non-liquefaciens; Leptothrix urethrae; 
Diplococcus candidus urethrae; Pseudogonococcus; Gonococcus of 
Neisser; Staphylococcus ureae liquefaciens; Streptococcus pyo- 



826 SURGICAL PATHOLOGY AND THERAPEUTICS. 

genes; Streptococcus liquefaciens urethrae; Sarcina urethrae; 
smegma-bacillus; tubercle-bacillus; Bacillus typhosus; Staphy- 
lococcus pyogenes aureus and albus; Streptobacillus anthracoides. 

The question of the kind of infection giving rise to the various 
ulcers and inflammatory processes of the external genitals will not 
be considered in this section. 

Bacteria of Cystitis. — The bacteria giving rise to or compli- 
cating cases of cystitis are as follows: Bacterium coli commune; 
Streptococcus pyogenes; uro-bacillus liquefaciens septicus (proteus 
Hauser); bacillus of tuberculosis; Bacillus typhosus; Diplococcus 
urese liquefaciens; Staphylococcus urese liquefaciens; Streptobacil- 
lus anthracoides; gonococcus of Neisser; Staphylococcus pyogenes 
aureus and albus; diplobacillus (Friedlander) ; Bacillus lactis aero- 
genes. 

In all probability, suppurative processes in the genito-urinary 
system can be attributed to the presence of one or more of the 
bacteria enumerated above; but not infrequently a cystitis is found 
to give only a pure culture. The most important of these micro- 
organisms will be considered in some detail. 

Bacterium Coli Commune. — This bacterium has been studied 
under a multitude of names; and it would seem to be without 
question the commonest cause of cystitis. Its presence is constant 
in the normal intestinal canal, and its virulence is increased in 
disease of that tract. In health it is commonly found on the external 
genitals. In cases of obstinate constipation it may enter the circu- 
lation, and then the urine via the kidneys; or it may pass directly 
through the rectal and bladder walls; but usually it reaches the 
bladder by extension up the urethra, with or without the aid of 
instruments. It is polymorphous; hence one cause of confusion in 
identification. It may multiply in the urine of a healthy bladder 
and give rise to no trouble ( lt bacteriuria "). Its virulence is very 
variable; it is pyogenic, probably decomposes urea very slightly, 
and may give rise to septicaemia. Unless mixed with decom- 
posers of urea or after prolonged retention in rare instances, it 
gives rise only to an acid cystitis. A pure culture is common. Its 
pathogenic property is enhanced in an alkaline medium. It may 
ascend to the kidneys and give rise to a suppurative pyelonephritis 
("surgical kidney"). 

Streptococcus Pyogenes. — Not such a common source of infec- 
tion as the preceding, but its presence is more serious. It is 
pyogenic, does not decompose urea, and hence in pure culture will 
give rise only to an acid cystitis. It commonly causes septicaemia; 
it penetrates the bladder-walls, causing lymphangitis, phlebitis, 
and even gangrene. Its presence should suggest greater care in 
the use of instruments and caution in considering the advisability 
of operation. Pyelonephritis is to be guarded against. Strepto- 
coccus pyogenes is the commonest germ of puerperal septicaemia. 

Urobacillus Liquefaciens Septicus {Proteus Hauser). — Polymor- 
phous, and characterized by the great energy and rapidity with 
which it decomposes urea. It is pyogenic, and has the power to 
cause a violent ammoniacal cystitis by first decomposing the urea, 



BACTERIOLOGY OF THE GENITO-URINARY SYSTEM. 827 

and thus predisposing the mucous membrane of the bladder to its 
own pyogenic action. It is prone to cause pyelonephritis. It is 
often a serious complication. 

Bacillus of Tuberculosis. — Not an unusual source of genito- 
urinary infection. Pyogenic; does not decompose urea; therefore 
gives rise to an acid cystitis when found in pure culture, which 
sometimes occurs; but more commonly it is associated with other 
micro-organisms, particularly the Bacterium coli commune and the 
Staphylococcus aureus. It does not grow on ordinary culture- 
media; therefore its identity must be verified by inoculation-experi- 
ments. In staining-properties it resembles the smegma-bacillus; 
but it differs in form, size, and grouping. 

Its occurrence in the genito-urinary tract may be primary or 
secondary. It is commonly secondary to foci in the lungs, first 
attacking the pyramids and pelves of the kidney, and later the 
bladder-walls about the orifices of the ureters. In primary cases 
the epididymis, kidneys, and Fallopian tubes are the commoner 
seats of origin. Tuberculous cystitis is insidious, runs a chronic 
progressive course, and frequently yields to no method of treat- 
ment. The urine remains acid, unless invaded by the more active 
decomposers of urea, and the lesions are located about the trigonum 
and the ureteral orifices. The bladder may contain bacilli of renal 
origin for a long period without any evidence of cystitis. Infection 
commonly extends to the prostate and the seminal vesicles, but less 
often to the kidneys than vice versa. Tuberculous cystitis is often 
the first warning given of the presence of tuberculosis which may 
have existed for a long period in the kidneys. 

The above characteristics apply to the chronic variety, and not 
to the acute miliary type, which is twice as common, but rapidly 
fatal without giving rise to ulcerative lesions. The prognosis of 
genito-urinary tuberculosis is very grave, and medicinal and sur- 
gical treatment offers but little encouragement in the great major- 
ity of cases. Like tuberculosis elsewhere, it is more amenable to 
hygienic and climatic treatment; but when primary in the epidid- 
ymis and Fallopian tubes surgical measures offer the greatest 
encouragement. 

Bacillus Typhosus. — Found in the urine in at least 25 per cent. 
of the cases of typhoid fever during convalescence. Not rarely 
associated with a moderate degree of nephritis, and occasionally a 
cystitis ; it is pyogenic, does not decompose urea, and is usually in 
pure culture; therefore gives rise to an acid cystitis. The presence 
of these bacilli in the urine is a dangerous source of infection to 
the community. 

Diplococcus Urecz Liquefaciens (Mel choir). — Rapidly decom- 
poses urea ; probably not pyogenic. 

Staphylococcus Urecz Liquefacieus. — Decomposes urea ; but 
slightly pyogenic ; always associated with a purulent ammoniacal 
urine. 

Streptobacillus Anthraco'ides (Melchoir). — Decomposes urea 
slowly ; non-pyogenic ; associated with an alkaline urine, but 
never in pure culture. 



828 SURGICAL PATHOLOGY AND THERAPEUTICS. 

Gonococcus (Neisser). — The micro-organism of specific urethritis 
(gonorrhoea), necessarily a mixed infection in the urethra, com- 
monly so in the bladder, but occasionally found in pure culture in 
cystitis. Pyogenic, but probably does not decompose urea. This 
is the commonest cause of suppuration in the female, and fre- 
quently causes purulent salpingitis and local peritonitis. 

Staphylococcus Pyogenes Aureus and Albus. — The common pus- 
producers. Usually associated with mixed infection in the blad- 
der, which tends to remain superficial and comparatively mild. 
They decompose urea, and they frequent the urethra in health. 
The aureus is the commoner, and is to be looked for as complicat- 
ing suppurative processes about the female genitals, and also in 
"surgical kidney." 

Diplobacillus of Friedlander. — Common in diverse suppurative 
lesions following pneumonia, and occasionally present in the urine 
even in pure culture. 

Bacillus Lactis Aerogenes. — Occasionally present, and gives rise 
to gas-production within the bladder. This may be the same germ 
found in puerperal emphysematous gangrene. 

Routes of Invasion of the Genito -urinary System by 
Micro -organisms. — In general, bacteria reach this tract by one 
or more of the following routes : i. Direct extension along the 
normal passages, favored or not by instrumentation. 2. Direct 
extension through tissues (lymph-channels or direct contact). 3. 
Hematogenic. 

External Genitals and Urethra. — As already mentioned, 
these localities are normally the abode of many pathogenic and 
non-pathogenic bacteria, and they are furthermore peculiarly ex- 
posed to invasion from external sources as well as to infection con- 
tained in urine. The likelihood of the involvement of these parts 
will depend upon their integrity and power of resistance on the 
one hand, and the virulence of the invading organism on the 
other. 

Bladder. — Inasmuch as the bladder-walls and urine are nor- 
mally sterile, infection must be conveyed from some external 
source; but whether such infection will cause a cystitis or not has 
been sufficiently considered. 

Urethral Origin. — In the female, infection often reaches the 
bladder spontaneously ; but in the male this happens less fre- 
quently. The constrictor urethrse muscle must be passed and the 
sterile posterior urethra reached, which is in one sense a part of 
the bladder, for its walls are directly continuous, with no barrier 
of separation. The introduction of instruments, even though 
sterile at the' outset, is the usual mode of infection. The instru- 
ment travels through a normally infected urethra, which is not 
generally irrigated before such introduction ; but, furthermore, the 
ordinary means of rendering the urethra aseptic are almost useless, 
and it is even questionable whether this passage can be made 
sterile with much degree of certainty. Probably bacteria are car- 
ried into the bladder with nearly every instrument; and a cystitis 
would be common if it depended solely on the presence of an 



BACTERIOLOGY OF THE GENITO-URINARY SYSTEM. 829 

exciting cause. However, other factors must coexist with such 
introduction, as demonstrated by clinical experience. The passage 
of instruments for urethral complications where the bladder is 
generally healthy and tonic does not give rise to a cystitis ; but 
where instrumentation is necessary for the relief of retention, the 
detection of calculi, cystoscopy, etc., where the integrity of the 
bladder-wall is involved — here a cystitis frequently follows where 
previously there was no evidence of such. The causes leading to 
the use of instruments in the bladder have already damaged the 
bladder-walls, and demand extreme precaution on the part of the 
surgeon. 

Extension from the Kidney. — In many of the infectious diseases 
bacteria are eliminated by the kidney, and thus reach the bladder, 
as shown particularly in typhoid fever, pneumonia, and erysipelas. 
This circumstance, however, does not usually give rise to a cys- 
titis. Tuberculous cystitis, however, commonly extends from a 
tuberculous pyelonephritis. 

Extension from Neighboring Organs. — In the female, inflam- 
matory disorders of the pelvic viscera may give rise to cystitis, and 
the route of infection is probably through the lymphatics. In 
the male there is evidence to show that the colon-bacillus may 
pass directly through the walls of the rectum and bladder into the 
urine. Occasionally abscesses may open directly into the bladder. 

Hematogenic sources of cystitis are possible, but not very prob- 
able. 

On account of the direct communication of the bladder and the 
posterior urethra (which are a single cavity from a bacteriological 
point of view) with other organs of the genito-urinary tract, a cys- 
titis or a posterior urethritis is most often the source of infection, 
resulting in acute prostatitis, vesiculitis, and epididymitis. 

Under favorable circumstances, certain varieties of infection are 
prone to extend from the bladder to the kidney without involving 
the ureter. Inflammation of the ureter is unusual, except at its 
extremities in tubercular processes, and along its course during the 
passage of calculi. 

Kidney. — The hematogenic sources of inflammatory processes 
in the kidney are common, consequent on the direct invasion of 
the micro-organism, and perhaps aggravated by their toxic 
products. 

It is open to question whether micro-organisms can pass through 
a perfectly healthy kidney; but when its nutrition is disturbed 
they pass readily from the blood into the urine. 

The nephritis accompanying the infectious diseases offers many 
examples: erysipelas, pneumonia, typhoid fever, streptococcus- and 
staphylcoccus-infection, and probably scarlet fever and diphtheria. 
Tubercle-bacilli reach the kidney through the blood generally from 
foci elsewhere. 

Under certain circumstances a cystitis may be a dangerous 
source of infection. 

In chronic cases of cystitis in elderly subjects, particularly when 
associated with prostatic or urethral obstruction or complicated by 



830 SURGICAL PATHOLOGY AND THERAPEUTICS. 

calculi, inflammation is prone to extend to the kidneys. Retention 
of urine, with consequent dilatation of bladder, ureters, and pelvis 
of the kidney, is a dangerous complication, and demands the 
greatest care with instruments and the strictest asepsis. A suppu- 
rative pyelonephritis may result, known as '* surgical kidney," 
which is not only serious to life, but it is also probable that the 
kidney never ceases to produce pus when once thoroughly infected. 
One kidney may become infected from below, and the other 
secondarily through the blood. 

Direct extension to the kidneys from neighboring organs is rare. 
Perinephritis is generally secondary to inflammation in the kidney. 

Prophylaxis and Treatment. — For the most part, only such 
questions will be considered as pertain to the bacteriology of the 
subject. 

Preparation of the Field of Operation. — If we" are unable to 
remove micro-organisms from the field of operation, then there 
must always remain a certain degree of danger accompanying the 
use of instruments. The question of asepsis is determined by 
bacteriological examinations; and these show that the ordinary 
routine of preparation of the external genitals is far from what 
could be desired. Furthermore, it is questionable whether we can 
sterilize these parts with any degree of certainty by any known 
methods, particularly without resulting in injury which may per se 
predispose the parts to later infection. Most of the antiseptics 
that are found to be reliable on cutaneous surfaces are too irritating 
when used profusely and in sufficient concentration on mucous 
membranes. 

Vicinity of Meatus Urinarius, Urethra, Bladder. — For the 
passage of instruments, the penis, including the glans and pre- 
puce, should be washed carefully with green soap and warm water, 
and then rinsed with sterile water. Then wash the same with a 
solution of corrosive sublimate, 1 : 3000, and rinse with sterile 
water or a saturated boric-acid solution (boric acid, so commonly 
used, is practically valueless as a germicide). Protect the parts 
with sterile towels. If possible, the patient should always urinate 
just previous to the above preparation; and it is probably wise to 
defer the passage of an instrument into the urethra until the latter 
has been flushed by the stream of urine, provided that such delay 
is possible and is not contraindicated. 

From the fact that the urethra is always the habitat of micro- 
organisms, it would seem that we ought to strive to disinfect it; 
but the usual antiseptic solutions are too irritating, so that harm 
rather than good is apt to follow. The best results are obtained 
from prolonged copious irrigations with a saturated boric-acid 
solution, the action of which is mechanical rather than antiseptic; 
but the great obstacle to this is the fact that it is tedious and is not 
practicable in a large clinic. 

Urethral irrigation, however, should be made use of in selected 
cases in which extreme caution is demanded. 

The bladder will need no preparation unless it is already the 
seat of inflammation. Previous to operation on this organ, it is 



JL 1 CTERIOL OG Y OF THE GENITO- URINAR Y SYS TEM. 83 1 

well to irrigate its walls with boric-acid solution or Thiersch solu- 
tion (ac. salicylates, 3ss; ac. borici, siiiss; warm water, Oij), 
the latter being valuable in removing the mucus. It is impossible 
to remove the micro-organisms imbedded in the bladder-wall. As 
a prophylactic after the passage of instruments through a morbid 
urethra into a healthy bladder, a solution of argentum nitratis, 
1 : 1000, may be injected into the bladder and allowed to remain 
about five minutes; then this is to be withdrawn and the bladder 
rinsed with boric-acid solution. 

Scrupulous cleanliness, should be exercised in relieving acute 
and chronic retention, and the volume of urine gradually reduced, 
as is customary in chronic cases. 

In all manipulations the greatest care should be used to avoid 
trauma. Unnecessary instrumentation is harmful. It is obvious 
that the hands of the operator should be clean. Enough has been 
said to show that certain cases are more susceptible to infection 
than others; nevertheless, this should be no excuse for careless- 
ness in detail in any case. 

Vulva and Vagina. — The vagina is the first of a series of pas- 
sages of communication between the exterior and the peritoneal 
cavity which nature carefully and successfully guards against the 
entrance of pathogenic bacteria unless certain conditions are over- 
come. These safeguards in the vagina are principally contact and 
integrity of its walls throughout, secretion of an acid mucus, and 
the presence of bacteria which may inhibit the action of noxious 
germs. For obvious reasons, our present methods cannot be relied 
upon to render these parts strictly aseptic, and the use of powerful 
antiseptics is contraindicated. 

Preparation of Vagina and Vnlva. — All hair should be shaven 
and the parts, including abdomen, buttocks, and thighs, most 
thoroughly washed with green soap and warm water, for this is 
probably the most important step in the preparation. All folds 
should be carefully cleansed, and the fingers and speculum used to 
expose thoroughly all parts of the vagina. Instead of a hard 
bristle brush for this delicate membrane, pledgets of cotton on 
forceps can be used somewhat vigorously, in order to remove 
mechanically all loose particles. Rinse with sterile water. The 
cutaneous surfaces are now to be prepared in the usual manner 
with potassium permanganate, etc. ; but this is probably too harsh 
for the vagina. After the soap and water have been washed out, a 
warm corrosive-sublimate douche (1 : 2000) should be given, 
followed by one of sterile water or creolin. If the uterus is already 
infected, preliminary curetting and local treatment may be neces- 
sary. 

Rectum and Anal Canal. — On account of the proximity of 
these parts to the female genitals, it is often well to render them as 
aseptic as practicable. As a preliminary step, the bowels should 
be thoroughly evacuated by cathartics, and then the rectum pro- 
fusely irrigated with high suds-enemata, followed by cleansing 
enemata of boric acid, Thiersch solution, or sterile water. The 
folds leading to the anal canal should be carefully separated and 



832 SURGICAL PATHOLOGY AND THERAPEUTICS. 

washed with green soap and water, using pledgets of cotton, 
followed by the usual cutaneous disinfectants about the anus. 

Preparation of Instruments. — Metallic instruments and soft- 
rubber catheters should be boiled or steamed. Woven instruments 
should be used as little as possible, on account of the difficulty in 
making them sterile ; but sometimes they are invaluable. They 
should be carefully washed with soap and water, both before and 
after use, and, in addition, they may be immersed in a solution of 
corrosive sublimate, 1 : 1000, and then thoroughly rinsed in sterile 
water. 

It is repeated here that care in avoiding trauma is a matter of 
the greatest importance. 

Metallic instruments should be warm when introduced, unless 
the patient is under the influence of an anaesthetic. 

Lubricaiits. — Sterile glycerine should be used in cases in which 
local applications are to be made, on account of its solubility. 
Sterile olive oil or liquid vaseline will serve the purpose in other 
instances. 

IyOCal Applications. — L,ocal applications may be of value either 
for their destructive action on micro-organisms or for some specific 
action on the mucous membrane. The list of local remedies for 
the various genito-urinary diseases in innumerable ; some of these 
drugs are of real germicidal value, others serve to decrease the 
amount of pus-formation, and some are only astringents. 

As a general rule, local applications are contraindicated in the 
early stage of acute inflammation of the mucous membranes; but 
meanwhile diluents and carminatives may be administered inter- 
nally. As the acute inflammation subsides, then local applications 
may be made use of, particularly for germicidal purposes; and for 
still later stages astringents will be more serviceable. There is 
but little danger attending the use of vaginal douches, which 
should be given warm and in copious amounts while the patient 
is recumbent, with the hips elevated. A fountain-syringe will be 
found most useful. 

Injections into the male urethra in cases of gonorrhoea should 
be administered only after the patient has urinated. Abortive 
injections in acute gonorrhoea are rarely efficacious after the gono- 
coccus has penetrated the mucous membrane and the exudate is 
purulent. As the acute symptoms subside the local injections may 
be used: first, with the idea of destroying as many bacteria as pos- 
sible, and, later on in the course of the infection, in order to serve 
as an astringent. A blunt-pointed syringe should be used, so as 
not to enter the urethra and injure the mucous membrane; and the 
force of the injection should be moderate, but at the same time 
sufficient to dilate the canal and obliterate all folds. The great 
danger in the use of injections in the male urethra is the liability 
of spreading the infection to deeper parts, and thus causing such 
complications as folliculitis and posterior urethritis. 

Injections intended for the posterior urethra (prostatic portion) 
are administered by means of a soft-rubber catheter or a metallic 
syringe. In certain cases, concentrated solutions of silver nitrate 



BACTERIOLOGY OF THE GENITO-URINARY SYSTEM. 833 

(1 per cent, to 5 per cent.) in very small amounts may be useful; 
but they demand precision and care. Copious irrigations with 
very mild germicides or astringents are often of greater service; 
and are applied to the whole length of the urethra, first irrigating 
the anterior and then the posterior urethra from behind forward as 
the catheter is slowly withdrawn, pausing for a moment at the 
constrictor muscle, so that the stream will flow both toward the 
bladder and out the external meatus. 

Posterior irrigations demand great care, for they are frequently 
the cause of extending the inflammation to the prostate gland, 
seminal vesicles, epididymis, and bladder. The onset of these 
complications demands the immediate cessation of all local treat- 
ment. 

Acute cystitis calls for general treatment by means of diluents 
and sedatives. Chronic cystitis is usually benefited by local irriga- 
tion — depending, however, on the variety of the infection, for 
tuberculous cystitis is apt to be aggravated thereby. For germi- 
cidal purposes the silver-nitrate solutions (1 : 3000 to 1 : 1000) give 
the best results ; but, nevertheless, the boric-acid solutions are fre- 
quently very effective in diminishing the amount of pus. In cer- 
tain chronic cases daily irrigations are necessary for the comfort 
of the patient, and these can often be performed by the patient 
himself. 

The most important drugs for local applications are as follows : 

Argentum Nitratis. — Silver nitrate would seem to be the sov- 
ereign local remedy as a germicide for the genito-urinary tract; and 
the inorganic salt would seem to be preferable to its various organic 
derivatives. Its prophylactic value against cystitis has been sug- 
gested. Its action is marked on all the pathogenic bacteria, in- 
cluding the gonococci, except the bacillus of tuberculosis, where 
its use has been of practically little avail. It should be used in 
solutions varying from 1 : 3000 to 1 : 500, according to circum- 
stances. 

Potassium Permanganate. — Solutions of 1 : 2000 to 1 : 1000 are 
frequently of great value. 

Corrosive Sublimate. — A powerful germicide, which must be 
used with care on the mucous membranes of the urethra and 
bladder, where a strength of 1 : 10,000 should not be exceeded. 
It should be washed out with sterile water or boric acid, in order 
to prevent absorption into the system. 

Boric acid does not possess germicidal properties of any value; 
but it is a very valuable aseptic wash which does not injure the 
mucous membranes, and has in a certain measure an antiseptic 
action in the suppurative processes to which they are subject. It 
is a very valuable drug for local use in the bladder, and should be 
prepared as a warm saturated solution (4 per cent.). 

Thiersch Solution is of value on account of its power of remov- 
ing mucus and the germicidal property of salicylic acid (its formula 
is given on page 831). 

Salt-solution is always to be obtained and is easily prepared. It 
is a good solvent for mucus, and therefore it is efficient in cleansing 
53 



834 SURGICAL PATHOLOGY AND THERAPEUTICS. 

the bladder- walls. Its strength should vary from that of the normal 
solution (0.6 per cent.) to about 12 per cent. 

Formaldehyde may prove to be a germicide of local value, but 
it is still in its trial stage. 

Internal Medication. — There are numerous drugs which act as 
astringents when eliminated by the kidneys; but laboratory experi- 
ments show that none is actively germicidal — except, perhaps, 
urotropine — in cases of the typhoid bacillus. Nevertheless, 
internal medication is of inestimable value for the inflammatory 
disorders of the urinary system. 

Balsams. — Sandal-oil and copaiba are invaluable in cases of 
gonorrhceal infection, and sometimes in other varieties of infection. 
The oleum santali is best administered in 10-minim capsules, 
giving one or two after each meal. Copaiba is more commonly 
administered in conjunction with other drugs, particularly sandal- 
oil, cubebs, and salol, combined in one capsule. Both drugs not 
uncommonly interfere with digestion, and copaiba may prove to be 
too strong an irritant to the kidneys, and may give rise to an 
extensive erythema, which often alarms the patient. 

Boric acid is eliminated as such by the kidneys, and decreases 
the suppuration in chronic cystitis; it is administered in 10-grain 
doses in a tumbler of water three times a day. 

Salol is one of the most useful of all the internal remedies for 
suppurative processes in the urinary system. It is best adminis- 
tered in pill or tablet form, giving 5 to 10 grains three times daily, 
after meals. 

Sodium benzoate, in 20-grain doses with plenty of water, may be 
administered with benefit. 

Urotropine is a new drug which seems to have a specific action 
in destroying the Bacillus typhosus, and favorable results are 
reported in other varieties of infection; but it is too early to draw 
definite conclusions. It is administered in water in 20- to 30-grain 
divided doses in twenty-four hours. 

It has been shown that local irrigations with large quantities of 
sterile or mildly antiseptic solutious are of great value on account 
of their mechanical action. The same principle is made use of 
internally by drinking large quantities of water, particularly for 
suppurative processes in the kidney. 



V. BACTERIOLOGY OF PERITONITIS. 

Peritonitis, localized or general, is always caused by bacterial 
invasion. It may be suspected that there are cases of peritonitis, 
the causative organisms of which cannot be isolated by our present 
culture-methods; and there is no question that some peritoneal 
infections are so virulent that death results so promptly that none 
of the usual signs of peritonitis is evident post-mortem. 

All the forms of pyogenic cocci have been found in the exuda- 



BACTERIOLOGY OF PERITONITIS. 835 

tion of peritonitis. The streptococcus is the organism most to be 
dreaded, although under certain conditions the colon bacillus may 
be possessed of equal primary virulence. The Staphylococcus albus 
is least virulent; and this organism, as also the citreus and the 
aureus, is often found in association with colon bacilli or strepto- 
cocci. At times the aureus may cause a very virulent peritonitis. 

The colon bacillus and its kindred, the Bacillus lactis aerogenes 
and the Bacillus fcetidus (for these two are admitted to be practically 
identical with the colon-bacillus), are not as yet entirely beyond 
dispute as causative agents of peritonitis. 

It may be that the colon bacillus is the vigorous, highly resist- 
ant organism that overgrows the causative germs, the absorption 
of which is already causing toxaemia. In general peritonitis from 
perforation of a typhoid ulcer the typhoid bacillus has never been 
found; but in most of the cases colon bacilli have predominated, in 
others pyogenic cocci. Klein found typhoid bacilli in the pus of a 
localized peritonitis after typhoid. Korte found typhoid bacilli in 
a case of general peritonitis originating from a suppurating mesen- 
teric gland in the course of typhoid fever, but not from intestinal 
perforation. This is of certain significance as supporting the 
theory that in peritonitis from intestinal perforation the causative 
germs may be overgrown by the other bacteria of the intestinal 
canal. Recent observers, however, are united in deciding that in 
many cases the colon bacillus is possessed of great primary viru- 
lence. 

Elting and Calvert, in a study of perforative peritonitis in dogs, 
found that the intense hemorrhagic peritonitis present in all cases 
gave definite bacteriological results in 20 cases out of 22. In 
18 cases members of the colon-group were found, 4 times alone, 
and 14 times in association; streptococci once alone, and 7 times in 
association. Staphylococcus albus was found in 5 cases, but 
never alone; Staphylococcus aureus once alone, and 3 times in com- 
bination. In these cases cultures were made in from six to twenty 
hours after perforation, and the colon-bacillus was the predominant 
organism. 

Orlowski of St. Petersburg has furnished the most recent work 
on this bacillus. He isolated n varieties, and found the most 
virulent to be what he calls the "ground type," farthest from the 
typhoid bacillus in its characteristics. He found a constant rela- 
tion between the virulence of these varieties, experimentally, and 
their power of milk-coagulation. Injections of the sterilized 
toxins always caused prostration and diarrhoea — not always death. 
Injections of living cultures, as well as the sterile toxins, into the 
peritoneal cavities of dogs or guinea-pigs always caused peritonitis. 

The pneumococcus can cause peritonitis. This infection may 
occur without the association of pneumonia. It is undoubtedly a 
rare infection, but may be extremely virulent. Morisse collected 
8 cases in which it was the only organism found. Rosthorn, in 
1895, reported 3 cases. Hartman and Morax report 2 cases. 
Reymond, in 1895, collected 6 cases. Flexner reported 2 cases, 



836 SURGICAL PATHOLOGY AND THERAPEUTICS. 

both fatal. Cases have been reported by Barbacci, Frankel, 
Sevestre, Netter, Gaillard, Wright and Stokes, and others. 

The Bacillus pyocyaneus is not infrequently found in association 
with other bacteria. It may increase the virulence of a mixed 
infection from intestinal perforation. 

Gonococci alone can cause peritonitis. There is, however, dif- 
ference of opinion on this point. McCosh reported a case of so- 
called gonorrhceal peritonitis in the male in which the cause was 
rupture of a periprostatic abscess. In this article he collected 8 
additional cases of gonorrhceal peritonitis from literature. In these 
cases there are no bacteriological examinations reported, and we 
must infer that the peritonitis was due to mixed infection with 
pyogenic organisms. Von Winckel speaks of gonorrhceal perito- 
nitis, but does not report any cases of peritoneal infection with 
gonococci. Cushing has reported 2 cases of diffuse peritonitis 
in which the gonococcus was the only organism found. 

The Bacillus aerogenes capsulatus has been found in a few cases 
of perforative peritonitis. It is not pyogenic alone, but in the 
presence of pyogenic organisms may be the main cause of death. 

A very rare form of peritonitis is caused by infection by the 
Bacillus proteus vulgaris. Only 1 case has been found — that 
reported by Flexner of Johns Hopkins University. This is the 
putrefactive organism found post-mortem in great numbers; but 
under normal conditions it is not pathogenic to man. This case 
was most carefully studied by Flexner, and he seems to prove 
beyond reasonable doubt that the infection was primary, and not a 
post-mortem invasion. 

Infection with any of the enumerated organisms will cause 
peritonitis of varying intensity and character, either local or gen- 
eral. The anatomico-pathological varieties have been best classi- 
fied by Pawlosky : 

1. An extremely toxic variety, the "mycotica," in which 
death may occur before reactive inflammation takes place on the 
peritoneal surfaces. In some cases the peritoneum may be covered 
with a slimy fluid containing a few blood-corpuscles, small flakes 
of fibrin, and many bacteria. There is no doubt that cases of such 
virulent infection occur that death results in a few hours, with all 
the symptoms of shock. 

2. An infection of great virulence is also manifest in the hem- 
orrhagic form, characterized by hemorrhagic extravasations and 
ecchymoses on the peritoneal surfaces of varying extent (with the 
intestinal coils markedly injected and distended), by a thin, brown- 
ish fluid exudation in which are pus-corpuscles and masses of bac- 
teria and fibrin, and by fibrin-flakes on the peritoneum. This is 
the common form met with in intestinal perforation. 

3. Fibrinopurulent and seropurulent peritonitis, characterized 
by a thin, seropurulent exudation with flakes of fibrin floating 
through it, and masses of fibrin on the peritoneal surfaces. This 
form is the first stage (according to Pawlowsky) of purulent perito- 
nitis. The seropurulent fluid is made up chiefly of pus-corpuscles 
and bacteria. 



BACTERIOLOGY OF PERITONITIS. 837 

4. Purulent peritonitis — a form characterized by au abundant 
purulent exudation of varying consistence. 

These forms must run together to a great extent ; no sharp 
division is possible. The kind of peritonitis met with will depend 
upon the kind of infection, its amount and virulence, and upon 
the intraperitoneal and systemic conditions in each case. 

The less serious forms of peritonitis are the nbrinopurulent and 
the purulent ; the most virulent, the hemorrhagic forms. The 
purulent forms are of longer duration, and may be caused by less 
virulent organisms or by smaller amounts of infection. 

Streptococci, colon-bacilli, and pneumococci are the organisms 
usually causing the rapidly fatal and hemorrhagic forms ; but they 
may, under certain conditions of virulence, amount, or tissue- 
resistance, cause the less fulminating and slower forms. Con- 
versely, while under usual conditions staphylococci may be 
expected to cause the less fulminating variety, they may, and 
especially the aureus, under changed conditions, cause the rapidly 
fatal types. 

Under abnormal conditions, bacteria possessed of little or no 
pathogenic power may cause a rapidly fatal peritonitis. In any 
condition where the fluids of the body depart from normal, where 
the vital resistance of the tissues is lessened and the peritoneum 
damaged, an infection usually of lesser amount may cause the 
gravest clinical picture. Such conditions are especially chronic 
renal or hepatic disease, with or without ascites. 

Perforation of the intestine is the commonest cause of the 
rapidly fatal hemorrhagic forms of peritonitis ; yet in intestinal 
perforation any form of peritonitis may be found. 

The serofibrinous, nbrinopurulent, and purulent forms are dif- 
ferent stages of a milder infection. In these forms operation is 
most favorable, for the fatal issue from toxaemia is delayed. In 
some of these cases the fluid exudation will be found sterile at the 
time of the operation. This does not mean that the process was 
an aseptic one from the start. The life of bacteria in the fluid 
exudation is frequently self-limited, and active organisms have 
been found in the fibrin-masses on the parietal peritoneum when 
cultures from the fluid exudation gave no growth. The fact that 
no culture-growth can be obtained is no proof that the individual 
may not have received previously enough sepsis to cause death. 
Sterile cultures are favorable prognostically, but they do not alter 
the fact that bacterial infection existed ; neither do they influence 
methods of operation. 

A knowledge of the histology of the normal peritoneum, and 
how fluids and solid particles are taken into the lymph- and blood- 
systems, is of the utmost importance to the abdominal surgeon; and 
a clear understanding of the changed conditions in a general or 
local peritoneal infection is of great moment in the surgical treat- 
ment of peritonitis. 

Muscatello, in 1895, reviewed all preceding study of the normal 
peritoneum and its absorptive channels, and his work has been of 



838 SURGICAL PATHOLOGY AND THERAPEUTICS. 

extreme service to abdominal surgeons. All careful investigators 
are agreed upon the following points : 

1. The absorption of fluids by the peritoneum is enormous. In 
an hour it will take up from 3 to 8 per cent, of the body-weight ; 
but under the influence of toxic or irritant substances an equal 
transudation into the peritoneal cavity may take place. 

2. Over the centrum tendinosum of the diaphragm, between 
the connective-tissue fibers in the diaphragmatic peritoneum, open 
spaces are situated, measuring from 4 to 16 millimeters ( T 3 g- to f 
inch) in diameter, and grouped in collections of fifty to sixty. 
These lymph-spaces exist nowhere else in the peritoneum; and 
through them the greatest absorption of both fluids and solid par- 
ticles takes place. Fluids may pass through the endothelium in 
many places, but the solid particles are absorbed only by these 
lymph-spaces in the diaphragm. 

3. Minute solid particles are carried from the peritoneal cavity 
through the diaphragm into the mediastinal lymph-vessels and 
glands, and thence into the blood-circulation, by which they are 
distributed to the abdominal organs, to appear later in the collect- 
ing lymph-glands of these organs. Larger sterile solid bodies are 
partly absorbed, and the remainder encapsulated. 

4. The leukocytes are largely the bearers of foreign bodies from 
the peritoneal cavity into the mediastinal lymph-glands. 

5. There is normally a force or current in the peritoneal cavity 
which carries fluids and foreign particles from the pelvis toward 
the diaphragm, regardless of the posture of the animal (though 
gravity may favor or retard the current greatly). 

Muscatello used carmine granules suspended in solution, in his 
experiments; and his work proves that bacteria and all solid par- 
ticles gain entrance to the system only through the lymph-chan- 
nels of the diaphragm and the mediastinal glands. This absorp- 
tion by the normal peritoneum is nature's safeguard against peri- 
tonitis. Colonies of bacteria are foreign particles that are absorbed 
by these lymph-spaces, just as the carmine particles in Muscatello' s 
experiments ; but the absorption of bacteria has definite limits, as 
will be seen. 

It is well known that certain amounts of bacteria will be taken 
care of by the peritoneum without peritonitis, if the peritoneum is 
normal structurally when the infection is introduced. The ability 
to remove bacteria and their products depends upon the kind and 
amount of infection, upon the systemic condition of the individual, 
upon the integrity of the peritoneum, upon the unobstructed con- 
dition of the diaphragmatic openings, and upon the presence or 
absence of culture-media in the peritoneal cavity. 

The experimental work of Wagner, Grawitz, Pawlowsky and 
Reichel, Orth, Waterhouse, and Halsted, from 1876 to 1892, is 
practically harmonious in these conclusions, and is of great in- 
terest. The early experiments dealt exclusively with less virulent 
germs — ^the staphylococcus group, especially the aureus. In 1895, 
Cobbett and Melsome performed some interesting and valuable 
intraperitoneal experiments with streptococci. 



BACTERIOLOGY OF PERITONITIS. 839 

Washburn, in 1895, experimented with the pneumococcus. One 
of his important points is, that death may result from toxaemia 
after intraperitoneal injections, and yet but slight signs of perito- 
nitis be present. 

Askanazy, in 1897, experimented on the introduction of the con- 
tents of the intestinal canal, and Orlowski on the injections of 
colon-bacilli, as has been noted. 

A study of the work of these men is very interesting, but the 
conclusions of all can be thus briefly stated : 

1. Normally the peritoneum can dispose of bacteria in varying 
amounts, depending on the virulence of the organism, without 
producing peritonitis; and the less the absorption from the peri- 
toneal cavity the greater the danger of infection. 

2. Death may result from general septicaemia, and not peri- 
tonitis, where large quantities of bacteria or bacteria of special 
virulence are taken up by the lymph-channels. 

3. Irritant material or trauma which destroys or injures the 
peritoneal surface, even in limited area, prepares a place for lodg- 
ment of germs which may be the starting-point of peritonitis. 

4. Stagnation of degenerated fluid in dead spaces favors the 
growth of organisms, and the presence of infected blood-clots is 
especially liable to cause a virulent peritonitis. 

5. Injury to the abdominal viscera^ as strangulation of an intes- 
tine, constriction and ligature of larger areas of tissues in the 
presence of pyogenic organisms, will almost certainly be followed 
by peritonitis. 

It has therefore been proved that the normal peritoneum, when 
unhampered by artificial conditions (as blood-clots, irritants, and 
trauma), can certainly dispose of certain amounts of pyogenic 
infection; but in direct opposition is the abnormal condition of the 
peritoneum in general septic peritonitis or in severe local peritonitis. 

In general peritonitis or severe local inflammatory conditions of 
the peritoneum the lymph-channels of the diaphragm are com- 
pletely choked by masses of bacteria, free and enclosed in 
leukocytes; these, by their mechanical obstruction, and also by 
setting up inflammation in surrounding tissues, effectually prevent 
absorption. Pawlowsky has shown that this obstructed condition 
of the lymph-channels always occurs, and has illustrated it very 
beautifully in a series of plates. Just as in Muscatello's experi- 
ments the absorbing channels of the peritoneum were filled with 
carmine granules, so in Pawlowsky's they were choked with 
bacteria and debris. This obstructed condition of these all-impor- 
tant absorbing channels occurs very early. 

Clark of Johns Hopkins University, accepting the facts of 
absorption and disposal of small amounts of infection by the 
normal peritoneum, reasoned that the slight infection occurring in 
the course of abdominal operations, such as contamination with 
pus or blood or septic fluids, would be taken care of by the absorp- 
tive channels of the peritoneum better than by intraperitoneal 
drainage. He maintained that drainage was used far too often, 
and that the normal peritoneum could take care of moderate con- 



840 SURGICAL PATHOLOGY AND THERAPEUTICS. 

tamination, if given favorable conditions, without drainage. The 
method advised by him for operations in which there had been 
septic contamination of a previously normal peritoneum, or where 
raw and oozing surfaces were to be left, was to wash out the 
abdominal cavity thoroughly with gallons of hot salt-soluton, 
leave in the peritoneal cavity 500 to 1000 c.c. , close the abdominal 
wound without drainage, and place the patient for twenty-four 
hours in a position with the pelvis elevated. By this technique he 
washed out most of the infection, and by filling the abdomen with 
salt-solution and elevating the foot of the bed he followed the 
known facts of Muscatello's experiments — namely, that there are 
currents in the intraperitoneal cavity carrying particles to the 
lymph-spaces in the diaphragm, which currents are best favored by 
gravity. This method Clark called "postural drainage." 

It is distinctly stated by Clark, and also by Finney, that this 
method must not be used in general peritonitis, but that in such 
conditions free drainage is demanded. 

All experimental evidence proves that in a very few hours the 
absorbing channels of the diaphragm are clogged with debris and 
bacteria. 

The keynote of the treatment of general septic peritonitis must 
be the relief of the peritoneum and these obstructed lymph- 
channels; and this can be done only by removal of the septic 
exudation and subsequent drainage. 

There can be no doubt that in many cases of localized peri- 
tonitis the integrity of the peritoneum is so damaged that it would 
not be safe to abandon drainage. The absorbing channels have 
become so clogged that any fresh infection during an operation on 
localized peritonitis could not reasonably be disposed of by them. 

A statistical study of the operative treatment of peritonitis is 
almost worthless, because of the confusion in the reported cases 
between general and localized peritonitis, because of the lack of 
evidence in regard to the kind of peritonitis found, and the absence 
of bacteriological reports. Early in the present decade some 
remarkable percentages of recovery were published by numerous 
surgeons. Stuehlen reported 78 cases, with 50 recoveries; and 
surgical literature from 1890 to 1892 abounds in equally glowing 
statistics. These reports were misleading in that the operations 
were mainly done upon localized pus-collections in the course of 
appendicitis. Such percentages of recovery from general peri- 
tonitis are yet beyond possibility. 

There are infections so virulent and so rapid that the profound 
toxaemia, even at the outset of the disease, must always forbid 
operative interference. 

Acute puerperal sepsis with peritonitis frequently presents a con- 
dition in which the entire system has received a fatal amount of 
poison. Operation for the peritonitis will not remove the main 
source of infection, and the operation which includes removal of 
the uterus, tubes, and ovaries can seldom be wise. There are cases 
of peritonitis of puerperal origin, not so acute, which offer a favor- 
able chance of recovery by operation. Such cases as von Winckel 



BACTERIOLOGY OF PERITONITIS. 841 

reports as successful operations for puerperal peritonitis are chronic 
cases, operated on weeks after the primary infection. 

The treatment by injections of antistreptococcic serum is as yet 
experimental and inconclusive. Wallick concluded that its use 
had not modified the mortality. 

Peritonitis associated with acute septic inflammation of the 
gall-bladder has been thus far uniformly fatal when operated upon. 
The infection is usually streptococci or colon-bacilli, and is of 
extreme virulence. 

Abbe has suggested that albumin in the urine of peritonitis 
cases is a contraindication to operation. There is no way of veri- 
fying this statement, because of the incomplete case reports. 

Cases of peritonitis occurring in the course of advanced renal 
and hepatic diseases — the cases of " terminal peritonitis" — cannot 
be regarded as suitable for operative treatment. 

Operations for typhoid perforation and for perforation of gastric 
or duodenal ulcers may be more accurately studied and the per- 
centages of recovery reasonably estimated. But a statistical study 
of the vast numbers of operations for general peritonitis from all 
other causes can give only one or two valuable points. The factors 
entering into each case are various, and differ with every indi- 
vidual; the virulence of the infection and the resisting powers of 
the patient cannot be estimated by statistics. The operation is 
dealing with a septic infection of varying virulence, which will 
cause death from toxaemia, and will be more successful as under- 
taken early in the infection. Operative methods must remove as 
much of the products of infection as possible; this can be done 
only by washing out and wiping the peritoneal cavity. The 
fact that one or two cases have recovered without drainage is no 
reason for deciding against it. 

Within five years opinions as to washing out and drainage have 
varied, but at the present time there is no uncertainty. Von 
Winckel, in his recent monograph on peritonitis, shows how those 
at one time denying the value of irrigation and drainage have been 
converted. 

Finney, in 1897, reported 5 consecutive successful cases — 1 in 
the course of a mild typhoid, and 4 caused by perforating appendi- 
citis. Cultures are reported in 2 cases; in 1 the infection was 
colon-bacilli and a doubtful coccus; the other was colon-bacilli 
and staphylococci. 

McCosh, in June, 1897, reported all his cases, and with special 
care 8 cases operated on in the year 1896. From 1888 to 1895 he 
had operated on 43 cases, with 37 deaths — a mortality of 86 per 
cent. Of the 8 cases operated on in 1896, all but 2 seemed in des- 
perate condition, but operation was considered the only possible 
chance for recovery. Of these 8 cases, 1 died as the immediate 
result of the operation, 1 died five weeks later of lung complica- 
tions, and 6 recovered. Bacteriological studies were made in 4 
cases ; in 2 streptococci were found, in 2 colon-bacilli. Six cases 
were caused by gangrenous appendicitis, 1 by a septic uterus, and 
1 by a perforating gastric ulcer. 



842 SURGICAL PATHOLOGY AND THERAPEUTICS. 

The methods of operating adopted by Korte, Finney, and 
McCosh differ but slightly, and illustrate the best technique to be 
employed. All use very free incision, median or lateral, fully 
exposing the peritoneal cavity, and in some cases make an addi- 
tional cut in the right or left flank for further exposure and drain- 
age. All remove the intestines from the abdominal cavity if the 
patient is not absolutely moribund, keeping them warm with hot 
towels and hot salt-solution irrigation, and cleansing them and the 
peritoneal cavity as thoroughly as possible by very free irrigation 
and by gentle wiping with gauze pads. Finney pays special atten- 
tion to wiping off the flakes of fibrin from the intestines and wiping 
out the abdominal cavity, and especially the pelvis. McCosh does 
this, but lays stress on irrigation. 

If the distention of the intestinal coils is too great to permit 
replacing them in the abdominal cavity, multiple aspiration or 
incision of them is done, with subsequent suture. Salt-solution at 
a temperature of 112 to 114 F. is the irrigating fluid used. All 
use drainage : Korte, gauze, or rubber tubes and gauze ; McCosh, 
gauze or strips of silk ; Finney, gauze. McCosh injects an ounce 
of Epsom salt into the ileum with a large aspirating-needle, clos- 
ing the puncture with a Lembert stitch before replacing. Few 
cases are so desperate as not to permit these extensive procedures. 
These details of operation are proved wise by experiment and 
investigation. 

The fibrin-flakes on the peritoneum may contain bacteria. 
Irrigation will not remove these masses, but gauze wiping will. 
In certain forms of peritonitis this fibrin clings so firmly to the 
bowel that considerable force must be used to remove it. These 
are likely to be fatal cases. Irrigation will carry off much of the 
exudation. Reichel has shown that the irrigating fluid will not 
return sterile, but that it will return clear. Calvert and Kiting' s 
experiments proved that constant irrigation of the intestinal coils 
with hot salt-solution will rapidly reduce congestion and distention. 

The use of chemicals, such as peroxide of hydrogen and corro- 
sive sublimate, which is advocated by certain surgeons, is shown 
plainly to be wrong by Thompson and by Walthard. From their 
experimental work it is certain that even weak solutions of corro- 
sive sublimate may of themselves cause peritonitis, and that sterile 
water is often irritating, but normal salt-solution is not. 



VI. BACTERIOLOGY OF THE GALL-BLADDER. 

The bacteriology of the gall-bladder relates essentially not to 
the organ itself, but to the bile for which it acts as a reservoir ; for 
pathological changes in the walls of the gall-bladder due to bac- 
teria, though they may in rare instances be primary, are, as a rule, 
secondary to the invasion of the bile by micro-organisms. The 



BACTERIOLOGY OF THE GALL-BLADDER. 843 

bile is not, therefore, as was formerly supposed, antagonistic to the 
growth of bacteria; but, on the contrary, allows the great majority 
of pathogenic organisms to flourish vigorously. 

The two chief channels of entrance by which bacteria reach the 
bile are the portal vein and the bile-ducts. Rarely the mode of 
ingress may be by the hepatic artery or the lymph-channels, but 
the importance of these two avenues for infection is comparatively 
small. 

Experimentally, organisms introduced into the portal vein or 
even the general circulation appear very soon in the bile ; and a 
similar process of elimination undoubtedly takes place in the 
human subject when a general septicaemia occurs, or when, by 
reason of pathological change in the intestinal mucous membrane, 
micro-organisms gain access to the portal vein. 

The ascending infection through the bile-ducts is determined 
largely by the character of the organisms in the duodenum and by 
the patency of the bile-ducts. 

The healthy duodenum is said to harbor colon-bacilli, staphylo- 
cocci, and streptococci ; abnormally, typhoid bacilli and pneumo- 
cocci ; but under normal conditions the bacteria do not leave the 
intestine, and the bile remains sterile. If, however, there be any 
obstruction to the flow of bile (calculi, malignant disease), or if the 
amount of bile be much decreased, as is said to be the case in 
acute infectious processes, conditions favorable to bacterial inva- 
sion are produced. 

The organism most often encountered in the bile is the Bacillus 
coli communis ; less often, the typhoid bacillus, bacillus of Fried- 
lander, streptococcus, Staphylococcus aureus and albus, and pneu- 
mococcus. The writer made bacteriological investigations in a 
series of 27 cases in which the gall-bladder was opened because of 
the presence of gall-stones or of inflammation from other causes, 
and a variety of the colon-bacillus was found 5 times ; the typhoid 
bacillus, 3 times ; Bacillus mucosus capsulatus, once ; pneumococ- 
cus, once ; and an unidentified diplococcus, once. In the other 16 
cases cultures were negative. 

The invasion of the gall-bladder by the typhoid bacillus is a 
subject of great interest, and its importance has been emphasized 
by a number of investigators during the last ten years. The 
observations of Chiari showed that in typhoid fever the bile is very 
commonly infected by the specific germ of the disease. Out of 22 
cases in which the bile was examined at autopsy, 19 showed the 
presence of typhoid bacilli. In 13 out of 19 positive cases the 
walls of the gall-bladder showed distinct evidence of inflammation. 
The inflammation was, to be sure, in most cases slight, affecting 
only the mucous membrane. In 1 case, however, all the coats 
of the organ were affected. Moreover, other observers have seen 
the pathological process go on to perforation and peritonitis. 

The 3 cases of typhoidal cholecystitis referred to above by the 
writer were of especial interest, because at the time of operation 
the nature of the affection was entirely unsuspected, and might 
have remained undetected had not the attending surgeon made 



844 SURGICAL PATHOLOGY AND THERAPEUTICS. 

cultures as a matter of routine. Furthermore, 2 of the 3 cases 
(as yet unpublished) must be regarded as primary rather than 
secondary typhoidal infections of the gall-bladder, to which latter 
group, of course, the great majority of these cases belong. In both 
instances the patients were operated on for impacted calculi. In 
Case I. the operation, at which many gall-stones were removed, was 
followed by typical typhoid fever, with relapse. In Case II. no 
stone was found, but the gall-bladder showed marked thickening 
and was bound up in old adhesions. The patient insisted, how- 
ever, that he had never been ill in his life until within two 
weeks. In both cases the blood showed well-marked typhoid 
reaction (Widal). In the light of this experience, it seems probable 
to the writer that a considerable number of these typhoidal infec- 
tions of the gall-bladder escape observation because many surgeons 
fail to follow up their cases bacteriologically. 

Another case was especially remarkable because of the specific 
blood-changes that were shown in it. The infecting organism 
in this instance was a bacillus having points of resemblance to 
both the typhoid bacillus and the Bacillus coli communis — a 
so-called paracolon bacillus. In this case the blood showed a 
well-marked specific reaction (Widal) with its own infecting or- 
ganism, but upon the typhoid and colon bacillus it had no effect 
whatever. 

Another fact of importance is that bacteria, having invaded the 
bile, may persist in it for great lengths of time. Von Dungern 
records a most remarkable case illustrating this point. The patient 
had been seized with biliary colic five years subsequent to an attack 
of typhoid fever. Symptoms of gall-stones recurred from time to 
time, but it was not considered necessary to operate until fourteen 
and a half years after the typhoid fever. At the operation, how- 
ever, together with many calculi, was found a pure culture of the 
typhoid bacillus. 

Moreover, this persistence of the typhoid organism in the bile 
should be borne strongly in mind in all cases in which at autopsy 
a previous typhoid fever is suspected, for it has been the experi- 
ence at the Pathological Laboratory of the Massachusetts General 
Hospital, not only that the bile was infected in practically every 
case, but also that the gall-bladder might be the only organ to 
show the specific organism. 

The relation of bacteria to the formation of gall-stones has been 
during the last decade the subject of much investigation, especially 
by French observers. In a considerable proportion of cases the 
gall-stones have been associated with bacteria, notably the Bacil- 
lus coli communis and the typhoid bacillus. Moreover, micro- 
organisms have been demonstrated in the center of certain biliary 
calculi. Thus, Gilbert and Fournier examined bacteriologically 
gall-stones from 27 different cases. The results were as follows: 
In 19 cases cover-glass examination and cultures were negative. 
These stones were all old. In 7 cases cover-glass examination 
and cultures showed Bacillus coli communis. Of these stones, 6 
were of recent formation; 1 was old. In 1 case culture was neg- 



BACTERIOLOGY OF THE GALL-BLADDER. 845 

ative, whereas cover-glass examination showed bacillary forms very 
imperfectly stained. 

The writer has investigated gall-stones in 10 cases, but has been 
able to demonstrate bacteria — Bacillus mncosns capsnlatns — in a 
single case only. In this instance the same organism was culti- 
vated from the bile. The stone examined was large, hard, 
stratified, apparently of considerable age, and its surface was, as 
far as could be seen, unbroken. It does not, therefore, seem prob- 
able that the bacilli soaked into the stone from the surrounding 
bile, though this mode of inoculation must always be considered as 
possible, especially in the softer stones of recent formation. 

The temptation to declare a causal relation between the bacteria 
and the stones is great. This relation is, however, far from estab- 
lished, though theoretically it has much in its favor. Thus it is 
argued that cholesterin and pigment are held in solution by the 
alkaline salts of the biliary acids. If now, for any reason (stagna- 
tion with absorption of water), the amount of cholesterin becomes 
excessive or the reaction of the bile becomes acid (acid-production 
of colon and typhoid bacilli), the conditions for the precipitation of 
biliary pigments and cholesterin are realized, and formation of cal- 
culi is determined. 

Furthermore, in the typhoid infection of the gall-bladder it was 
noted by dishing and the writer that the bacilli were often 
arranged in large clumps; and these collections of bacteria were 
frequently associated with considerable masses of pigment and 
debris. There was therefore suggested the possibility that these 
aggregations of bacilli and pigment would serve as excellent nuclei 
for the formation of calculi. The typhoid organisms might in 
this case act in two ways: First, to cause an acid reaction in the 
bile, with consequent precipitation of cholesterin and pigment; 
secondly, to serve as nuclei upon which the stones should form. 

As already stated, the subject has been a favorite one with 
French observers, and a great many investigations have been 
made, especially by Gilbert and his associates, Fournier, Dominici, 
and Claude. 

In experiments upon rabbits, Gilbert succeeded in producing a 
calculus as large as a grain of wheat by injecting into the gall- 
bladder three drops of a typhoid culture which had been heated for 
ten minutes to 50 C. 

Mignot introduced his bacteria upon pledgets of cotton. After 
a number of days the cotton was removed. The bacteria, then 
left to themselves, produced in one-third of the cases regularly 
stratified cholesterin calculi. 

The writer, working on the "clump" theory of origin for 
biliary calculi, injected into the gall-bladder of a rabbit typhoid 
bacilli which had been agglutinated by the addition of typhoid 
serum. In this case, after four months a brown calculus, the size 
of half a pea, v/as found. 

In its clinical aspect this relation between typhoid fever and 
gall-stones has been the subject of especial study by Dufourt, who 
records 19 cases in which enteric fever was followed by distinct 



846 SURGICAL PATHOLOGY AND THERAPEUTICS. 

symptoms of cholelithiasis. Previous to the typhoid there had 
been nothing to suggest the presence of calculi in the gall-bladder. 
In 12 cases the symptoms appeared within six months of the 
typhoid attack; in the other cases the interval was much longer, 
and a connection between the two pathological conditions was more 
difficult to trace. Dufourt acknowledges that the gall-stones may 
have been present without causing symptoms previous to the 
typhoid fever, but he does not consider this probable. 

The evidence seems, therefore, quite strong that bacteria do 
have an important part in the formation of gall-stones; but much 
more extended investigation is needed before well-defined con- 
clusions can be drawn. 



VII. SERO=THERAPY IN TETANUS, TUBERCULOSIS, AND 

SYPHILIS. 

Tetanus. — The fact that sero-therapy in diphtheria has more 
than justified its early promise as a life-saving treatment has given 
grounds for hope that the antitoxin of other diseases, notably 
streptococcus-infection and tetanus, might also be brought under 
control by the antitoxins produced by the growth of the organisms 
themselves, and of recent years great activity has been shown in 
the endeavor to elaborate and apply in both experimental and 
clinical work the antitoxin treatment to tetanus and streptococcus- 
infection ; but in both these diseases the difficulties met with in 
the endeavor successfully to put in practice the antitoxin treatment 
have been much greater than was the case in diphtheria. In the 
case of tetanus the chief difficulty has consisted in the fact that 
during the incubation of the disease, and even before the first 
symptoms have developed, in animals at least, so large an amount 
of toxin has been absorbed, and perhaps fixed, in the system that 
the most concentrated antitoxic serums which it has so far been 
found possible to produce have been found to be too weak to neu- 
tralize them. 

In order to save the life of a horse inoculated with tetanus- 
toxin, it is found necessary to inject the antitoxin before the symp- 
toms have appeared. This fact does not hold true in man, as in 
the human subject tetanus is a vastly more variable disease, and 
less uniformly fatal, than in horses. As is well known, the mor- 
tality in human tetanus varies with the acuteness of the case, 
especially as manifested by the time of onset of the symptoms. 
Rapidly progressing cases, in which the symptoms appear early, 
give a mortality of 90 per cent, and upward. In the class of cases 
in which the symptoms appear later aud progress slowly the mor- 
tality has been estimated at only about 40 per cent. 

The difficulty in securing an effective antitoxic serum for use 
in human tetanus is greatly enhanced by the fact that the acute and 
virulent cases, which have the highest mortality and in which the 



SERO-THERAPY IN TETANUS, ETC. 847 

need for a suitable antitoxic serum is greatest, are the very cases 
in which the disease most nearly approaches the type seen in 
horses — when, by the time the symptoms have appeared, so large 
an amount of toxin has been absorbed into the system that the 
strength of the antitoxic serum has been too slight to cope with it 
effectively. There has been no evidence so far published that the 
antitoxin treatment has lessened the mortality of the very acute 
cases. 

Carefully compiled statistics of 167 cases of tetanus treated by 
antitoxin up to June, 1898, 1 gave a mortality of about 40 per cent, 
for all cases treated by the subcutaneous injection of antitoxin, as 
against a roughly estimated mortality, for all cases of the disease 
under previous methods of treatment, of 60 per cent. These 
statistics are open to criticism, owing to the not infrequent failure 
to record unsuccessful cases, and the fact that in many of the cases 
that were treated by antitoxic serum the dosage was so small and 
the strength of the serum so various that it becomes extremely 
difficult to decide in any case that recovered whether the recov- 
ery was due to the serum or not. The amelioration of symptoms 
that so definitely follows the administration of antitoxin in diph- 
theria does not occur in tetanus. 

Of all the experimental workers who have engaged in the prep- 
aration of antitoxic serum, Behring alone has produced a dried 
serum of considerable condensation and of an antitoxic strength 
of 100 units to the gram of the dry powder (the unit is the amount 
of antitoxin that will neutralize 1,000,000 minimum fatal doses 
for a 250-gram guinea-pig). The strongest liquid serum which 
Behring has put on the market contained 5 units to the cubic 
centimeter. The serum produced by the Massachusetts State 
Board of Health contains 1 unit to the cubic centimeter, and it 
is probable that the majority of the antitoxic serums on the 
market do not exceed this in strength. 

As a result of experimental and clinical work, Behring has con- 
cluded that in the human adult no less than 500 units must be 
administered at one dose in order to prove effective against the 
tetanus-toxin. With a serum of 1 unit to the cubic centimeter it 
would therefore be necessary to administer 800 c.c. at a single 
dose in order to have any reasonable probability of affecting favor- 
ably the course of the disease. In the vast majority of the reported 
cures the dose has been from 10 to 40 c.c. of the serum, so that 
it seems hardly reasonable to suppose that the course of the disease 
has been favorably or unfavorably influenced thereby. 2 

In order to secure the immediate action of the antitoxin in the 
largest possible quantities upon the nerve-centers of the body, it is 
advisable to administer the serum by intravenous infusion. This 
is especially true of trie serums of which a large amount must be 

1 Lund, Boston Med. and Surg. Jour., Aug. 18, 1898. 

2 A recent test by Theobald Smith of the tetanus-serum furnished in sealed tubes by 
Tavel of Zurich, of which the dose advised is 10 to 20 c.c, showed that it was at least 
10 per cent, weaker in antitoxic strength than that furnished by the Massachusetts State 
Board of Health. It must therefore contain less than I unit of antitoxin per cubic centi- 
meter, and the dose advised must be utterly inadequate. 



848 SURGICAL PATHOLOGY AND THERAPEUTICS. 

employed, owing to the slowness and difficulty of administering 
large quantities of fluid hypodermically. The serum should be 
warmed to a temperature of 101 or 102 ° F., and, of course, all 
antiseptic precautions should be taken. The serum, when ob- 
tained from the manufacturers, is put up aseptically in sealed 
receptacles. It should be kept on ice in a dark place. 

With a view of obtaining immediate action upon the nerve- 
centers, by which experimental work has shown that the tetanus 
toxin is fixed, and into combination w r ith which it enters, the 
intracerebral injection of from 4 to 6 c.c. of the serum has been 
practised during the past years. 

Roux and Borel found that the intracerebral injection of anti- 
toxin was effective in guinea-pigs, and more so than the subcu- 
taneous injections. 

In the human subject, in December, 1898, the intracerebral 
injection had been practised in 12 reported cases, of which 5 died. 
As was to be expected, the fatal results occurred in the more acute 
type of cases. One unreported acute case is known to the writer, 
in which death followed intracerebral injection. 

In case this operation is practised, it is advisable to administer 
the serum intravenously as well, in order, if possible, to neutralize 
any toxin which may already be circulating in the blood. About 
3 c.c. of antitoxin are injected into the center of the frontal 
lobes, slowly, in order not to injure the brain-tissue. A small 
trephine-opening must be made on either side. Owing to the 
small number of cases reported, the value of this procedure remains 
in doubt. 

Recent experience with intracerebral injections of the serum 
have failed to establish its value. 

It is difficult, for the same reason, to form an estimate of the 
value of the antitoxin treatment as a whole, owing to the varying 
gravity of the disease and the small number of cases that fall 
within the experience of any single observer. There is good rea- 
son for hope, however, that with the amount of activity that is 
being shown by laboratory workers in endeavoring to produce 
antitoxic serum of greater strength, and by clinicians to perfect 
methods of administration, the treatment may in the not distant 
future become an efficient aid in lessening the mortality of tetanus. 

The Antistreptococcic Serum. — In 1895, Marmorek, using 
the horse and the ass for immunization against streptococcus-infec- 
tion, produced a serum which, if injected into rabbits sufficiently 
early after a fatal dose of the streptococcus toxin, would protect 
the animal against the latter. The amount of serum which it was 
necessary to employ, however, increased rapidly with the time 
after the toxin was given, and in the case of 10 times the fatal 
dose of a very virulent culture it was found that no amount of 
antitoxic serum, if injected more than six hours after the original 
injection, would protect the animal. In the case of less virulent 
cultures the infection might be checked twenty-four to thirty 
hours after the injection. 

Koch and Petruschky have shown, however, that the virulence 



SERO-THERAPY IN TETANUS, ETC. 849 

of a streptococcus culture for animals was no index of its activity 
for the human subject, and found that no effect was produced on 
man with several cultures which were highly virulent for rabbits. 

Petruschky also found that neither Marmorek's nor Aronson's 
serum sensibly modified the course of an erysipelas produced in the 
human subject by inoculation with a culture from human erysipelas. 

In puerperal fever, according to Cotton, 1 the serum had been 
employed in 107 cases, with 34 deaths — a mortality of 31.7 per cent. 
In erysipelas Marmorek reports 413 cases, with a mortality of 3.87 
per cent., as against a mortality of 5. 12 per cent, in previous cases 
treated in the same service. 

In regard to other general infections — pyaemia, endocarditis, 
osteomyelitis, etc. — too few cases have been reported to enable any 
conclusion to be drawn. 

In attempting to estimate the value of the serum, we are con- 
fronted by the fact that we are dealing with isolated cases seen by 
different observers, and with a disease which runs no definite and 
typical course. 

In Marmorek's series of erysipelas, the only large series treated by 
a single observer, the reduction in the mortality was very small, and 
within the limits of variation in the mortality of the untreated 
disease. An improvement in the subjective symptoms immediately 
following the administration of the serum occurred in a certain 
number of cases, but was not by any means constant. 

Cotton 2 concludes that although the serum is not, broadly 
speaking, effective against streptococcus-infections, a certain degree 
of passive protection is certainly present in the laboratory-experi- 
ments, and something of the sort is possible in man. He advises 
further trial of the serum as a symptomatic and adjuvant to other 
treatment, if nothing more. In no case should it be employed to 
the exclusion of stimulation and other methods of treatment, as 
advised by Marmorek, but only in conjunction with them. It 
should be employed in doses of from 10 to 25 c.c. ; and care should 
be taken to select a serum the preparation of which is known to 
have been conscientious. 

Surgical Tuberculosis. — It is chiefly in the field of pulmonary 
tuberculosis that the serum treatment has been employed. The 
serums employed have been obtained from horses subjected to 
treatment by injections of tuberculin or the new tuberculin T. R. 
of Koch. The results have been in the early cases favorable, and 
in the advanced cases with mixed infection the treatment has 
naturally done no good. The fact that the early cases have so 
often done well under the climatic and general hygienic treatment 
with which the serum treatment has been naturally conjoined 
renders it impossible to form an estimate of the value of the latter. 

In surgical tuberculosis such good results are attained by 
immobilization combined with hygienic treatment, ablation of the 
foci by operations, etc., that the reasons for the employment of the 
serum treatment in the early cases — the only ones in which it could 
render any promise of being effective — have not demonstrated 

1 Boston Med. and Surg. Jour., Feb. 2, 1899. 2 Loc. cit. 

54 



850 SURGICAL PATHOLOGY AND THERAPEUTICS. 

themselves sufficiently to lead to its general employment. The 
chronicity of the disease and the length of time during which the 
treatment would have to be continued have militated against its 
trial. 

The infectious granulomata, such as syphilis and tuberculosis, 
are so manifestly different in their nature from the acute infectious 
diseases in which antitoxins have proved of value that the success- 
ful application of the antitoxin treatment is in them fraught with 
additional difficulties, and the extension of the principle of 
immunity to them is a matter of doubt. 

Syphilis. — Acting on the theory that immunity from syphilis 
is present in those who have previously passed through the dis- 
ease, numerous attempts have been made in the treatment of this 
disease with the serum of animals, the serum of syphilitic patients, 
the serum of animals previously treated with mercury, etc. No 
definite results have so far been reported. 



INDEX OF NAMES. 



Abbot, 202 
Abemethy, 633 
Adamkiewicz, 699 
Adams, Z. B., 572 
Albarran, 720 
Albers, 579 
Albert, 442, 693 
Alibert, 660 
Allingham, 561 
Amidon, 444 
Anagnostakis, 785 
Andrews, 580, 662, 672 
Arnd, 693 
Arning, 65 
Ashhurst, 392, 686 
Askanazy, 839 
Assaky, 243 
Aufrecht, 444 

Babes, 25, 45, 470, 472, 474, 
482, 485, 486, 559, 574, 

576, 5»5» 595, 709 
Baker, 677, 696 
Balbiani, 640, 642 
Ballance, 220, 254, 379 
Baltzer, 729 
Banks, 669 
Barbacci, 836 
Barbieri, 385 
Barker, 678, 683 
Bartacci, 49 
Baumgarten, 25, 38, 45, 56, 

61,62,74,75,77,107,143, 

145, 146, 33%, 360, 373, 

383, 384, 486, 507, 508, 

612 
Beach, 243, 794 
Becker, 43 

Behring, 153, 450, 847 
Belfield, 469 
Bell, Hamilton, 404 
Bell, John, 295 
Bell, Joseph, 659 
Bender, 584 
Bennett, 357 
Berard, 487 
Berger, 288 

Bergmann, 24, 336, 787, 799 
Bernard, Claude, 79, 82, 114, 

116, 290, 305 
Bernhardt, 442 
Besnier, 558 
Besser, 338, 359 



Betoli, 436 

Bichat, 289, 633, 634 

Bigelow, 385 

Billings, 643 

Billroth, 135, 140, 144, 277, 
282, 289, 290, 314, 326, 
3 2 9, 334, 3 6 7, 372, 374, 
3 8 4, 435, 5*4, 5 2 3, 539, 
545, 548, 550- 55i, 664, 
668, 669, 678, 683, 689, 

703, 723, 729, 740, 7 6 8 
Binaghi, 800 
Biondi, 143 
Birch- Hirschfeld, 752, 753, 

758,761,767,770,776,783 
Birdsall, 460 
Bischer, 746 
Blodgett, 464 
Blum, 278, 281 
Blumberg, 803 
Bockhart, 139 
Bode, 694 
Boll, 636 
Bollinger* 76, 469, 475, 487, 

491, 509, 510, 515 
Bonome, 70, 145, 146, 360, 

493 

Booker, 49 

Bordoni, 65, 70 

Borel, 848 

Borner, 125 

Bostrom, 470, 474, 475 

Bosworth, 728, 753 

Bouchard, 47 

Bourgeois, 480 

Bowen, 562 

Boyle, Robert, 17 

Bradford, 523, 536, 539, 540, 
554, 603, 604, 609 

Braidwood, 369, 376 

Brandenburg, 515 

Brewer, 805 

Brieger, 24, 55, 436 

Bristowe, 288, 377, 424 

Brock, 558 
I Brodie, 533, 761 

Brodinsky, 729 

Brouardel, 456 
1 Brown, 563 

Brown-Sequard, 84, 282, 305, 
444, 46o 

Brugmanns, 418 

Brunner, 441, 442 



Bruns, 249, 250, 626, 747 

Brunton, L., 292 

Bryant, 663 

Buchner, 20, 41, 73 

Bucq, 563 

Budor, 695 

Bull, 669 

Bumm, 51, 52, 139 

Busch, 600, 619 

Busch, W., 401 

Butlin, 657, 658, 659, 679, 

684, 689, 690, 692, 693. 

697, 725, 727 
Buxton, 736 

Cabot, 720 

Cabot, R. C, 100 

Cabot, S., 385 

Cagniard-Latour, 17 

Calmette, 502, 503 

Calvert, 835, 842 

Carmalt, 645 

Cattani, 451, 804 

Cayla, 575 

Cenkowski, 74 

Chamberlain, 69 

Chandler, 412, 413 

Chapman, 644 

Charrin, 594 

Chassaignac, 211 

Chauveau, 69, 341 

Cheever, 212, 286, 297, 298, 
725, 726 

Cheyne, 137, 141, 142, 144, 
148, 149, 150, 151, 338, 
341, 506, 507, 510, 518, 
519, 520, 530, 535, 537 

Chiari, 843 

Chiene, 672 

Chomel, 402 

Christmas, 141 

Clark, 807, 839, 840 

Clark, Le Gros, 292 

Clarke, Lockhart, 444 

Claude, 845 

Cleveland, 419, 420, 432 

Cobbett, 838 

Cohen, 727 

Cohn, 22 

Cohnheim, 56, 92, 94, 95, ioi, 
102, 103, 104, 106, 113, 
116, 118, 135, 218, 309, 
504, 635, 636, 703 

851 



852 



INDEX OF NAMES. 



Coley, 401, 734, 735, 806 

Colin, 570 

Colles, 445 

Cooper, Sir Astley, 277, 282, 

291 
Cornet, 61, 509 
Cornil, 25, 104, 149, 402, 508, 

5io, 559, 574, 576, 595 
Cotton, 849 
Councilman, 53, 140, 574,639, 

643, 708 
Courmont, 1 94 
Coze, 336 
Crocker, 741 
Cruveilhier, 356, 375 
Curling, 439 

Curtis, 457, 460, 461, 464 
Cushing, 836 
Czerny, 686, 689, 690, 692 

Dana, 459 

Darier, 641, 642, 671 

Davaine, 17, 18, 71, 336, 

477 

Davidson, 100 
De Bary, 19, 140 
Decroix, 486 
Delapine, 640 
Delpech, 409 
Dernarquay, 657 
Dennis, 669 
Desportes, 439 
Dexter, 381 
Dietrich, 663, 669 
Disse, 67 
Dbderlein, 805 
Doleris, 358, 455, 458 
Dominici, 845 
Dufourt, 845, 846 
Duhring, 276 
Duncan, 337, 344, 677 
Dupuytren, 439, 590 
Duret, 297 
Dussaussoy, 409, 418 

Ebermaier, 196 

Eberth, 729 

Edwards, 220, 254, 729 

Eiselberg, 144, 338 

Elting, 842 

Englisch, 581 

Erichsen, 725 

Ernst, H. C, 48, 61, 136, 143, 

456 
Ernst, Paul, 48 
Escherich, 48 
Esmarch, 561 
Etiolles, Leroy d', 636 
Eulenburg, 280 
Eve, 66 
Ewart, 499 
Eyles, 276 

Falk, 279 
Farr, 17 



Fayrer, 495, 497, 499, 500 
Fehleisen, 382, 734 
Fehling, 600, 602 
Felix, 421 
Feltz, 336 
Fenger, 697 
Fenwick, 696, 720 
Feoktistow, 497, 502 
Ffolliott, 325 
Filene, 296 
Finney, 840, 841 
Fischer, 278, 279, 280, 281, 
288, 289, 296, 418, 613, 

6i5 

Fitz, 462, 463 

Fleischmann, 634 

Flemming, 104, 219 

Flexner, 732, 733, 835 

Fliigge, 69 

Fol, 455 

Foote, 270 

Forcade, 612 

Fournier, 844, 845 

Frankel, 25, 37, 40, 47, 49, 

61, 198, 486, 508, 836 
Frothingham, 55 

Gaillard, 836 

Gamaleia, 459 

Gamgee, 378 

Gannet, 679 

Gardner, 579 

Garre, 42, 138, 172,420, 590, 

591 
Gartner, 150 
Gaskell, 306 
Gaspard, 335, 349, 357 
Gay, Geo. H., 780 
Gay, Geo. W., 289, 291, 293 
Gay-Lussac, 17 
Gensmer, 132 
Gibney, 614 
Gifford, 817 
Gilbert, 844, 845 
Glax, 96 
Godwin, 70 
Goldsmith, 411, 432 
Goltz, 82, 84, 85, 279, 280, 

281, 289 
Gosselin, 392, 402 
Gottstein, 800 
Gowers, 461, 462, 463, 467, 

732 
Graefe, 123 
Gram, 43, 46, 48, 49, 5°, 5 2 , 

64, 66, 67, 68, 72, 77, 135, 

270 
Grawitz, 105, 106, 140, 220, 

221, 742, 838 
Gray, 460, 725 
Greenfield, 747 
Grinelle, 444 
Grivet, 400 
Gronin, 477 
Groningen, 85, 280, 281, 282, 



283, 285, 287, 288, 289, 

291, 292, 300 
Grosch, 762 

Gross, S. D., 278, 280, 287, 

292, 725 

Gross, S. W., 663, 669, 697, 
713, 714, 715, 716, 719, 
724, 725, 738 

Gruber, 613 

Gubler, 641 

Guerin, 378 

Gueterbock, 442 

Gussenbauer, 288, 339, 342, 

346, 35°> 363, 369, 377, 

652 
Gusserow, 676, 721 
Guthrie, 277 
Guyon, 695 

Hacker, von, 686 

Haidenhain, 261, 264 

Haight, 86 

Hall, 381 

Halsted, 150, 572, 788, 802, 

805, 838 
Hamilton, 271 
Hammic, 67 
Hanau, 643 
Hankin, 153 
Hansen, 64 
Hare, 296 
Harrington, 340 
Hartman, 835 
Haviland, 642, 643 
Hebra, 755 
Hegar, 575 

Heine, 416, 420, 421, 426 
Heitzmann, 603 
Hesse, 704 
Heuppe, 40 
Heuter, 122, 140, 348, 359, 

367, 388, 399, 406, 433 
Hewitt, 579 
Hinterstoiser, 719 
Hippocrates, 356, 447, 785 
Hirt, 617 
His, 745 

Hochenegg, 473, 475 
Hodge, 285 
Hoffa, 324, 325, 326, 327, 

348 
Hofmeier, 677 
Hofmeister, 370 
Holmes, Bayard, 492 
Holmes, O. W., 386 
Holmes, T., 212 
Homans, 725, 726 
Homes, E., 500 
Hooper, 728 
Horner, 500 
Horsley, 324, 350, 379 
Howell, 238, 239, 240 
Huber, 149, 238, 239, 240 
Hunter, 92, 1 15, 117, 288, 

356 



INDEX OF NAMES. 



353 



Hutchinson, S5, 305, 376, 
617, 654, 755. 756, 761, 
769 

[AKOWSKI, 4S 

Israel, 76, 469, 485, 697 

Iversen, 692 

Taboulay, 194 
Jack, 379 

Jeffries, 49, 790 

Jensen, 470 

Jewell, 444, 448 

Johne, 470 

Jones, Joseph, 41 1, 412, 413, 

414, 418, 420, 427, 428, 

431 

Jordan, 277, 294 

Kalming, 492 

Kaposi, 712 

Karlinski, 478 

Kassowitz, 603, 609 

Kaufrnann, 581, 657 

Keen, 85, 87, 124, 410, 411, 

420,431 
Kelley, 803 
Kelsey, 692 

Kitasato, 54, 55, 153, 45° 
Klebs, 67, 576, 579, 610, 643, 

694, 746, 752 
Klein, 835 
Klemm, 442 
Knapp, 136, 730, 760 
Knecht, 448 
Knie, 686 
Koch, 18, 31, 32, 34, 42, 48, 

56, 59, 61, 67, 70, 71, 74, 

296, 337, 338, 356, 383, 

415, 478, 479, 493, 5°5, 
515, 558, 699, 848 

Koch, W., 70 

Kocher, 149, 194, 210, 576, 

577, 681, 682, 683, 684, 

698, 722, 723 
Koenig, 524, 528, 545 
Kolesnikoff, 462 
Kolliker, 238, 242, 244 
Konetschke, 325 
Konig, 583 
Koplik, 196, 205 
Koionyi, 479, 484, 487, 491 
Korte/835, 842 
Koster, 533 
Kraske, 195, 693 
Krause, 515, 516, 522, 525, 

533, 538, 540, 546, 548, 

556 
Krebs, 242 
Kubasoff, 637 
Kiister, 669, 694, 695 
Kyle, 818 

Lacerda, 502 
Laennec, 504 



Landerer, 96, 1 13, 243, 514, 

594, 800 
Langenbeck, 469, 636 
Langenbuch, 284 
Langhans, 581, 721, 743 
Lannelongue, 211, 464 
Larrey, 435, 439, 444, 445 
Lathrop, 61 1 
Latta, 277 
Laveran, 444 
Lawrence, 511 
Leber, 141 

Lebert, 469, 634, 636 
Leeuwenhoek, 17 
Legg, W., 463, 711 
Leichtenstern, 729 
Leloir, 561 
Letievant, 243 
Lewisson, 284 
Leyden, 283 
Liborius, 69 
Liebig, 17 
Lietzmann, 601 
Lilienfeld, 311, 312 
Lingard, 66, 70, 270 
Lister, 122, 139, 215, 333, 

801, 805 
Litten, 332 
Lobker, 243 
Lobstein, 633 
Loffler, 61,485 
Lombard, 84 
Lovett, 523, 603, 609 
Lucan, 498 
Lustgarten, 65, 66 

MacAllister, 306 

Macewen, 379 

Mackenzie, 684 

Maclagan, 310 

Macleod. 410, 420, 428 

Madelung, 761 

Maissonneuve, 394 

Makin, 202 

Malassez, 595 

Malphigi, 612 

Mandry, 583 

Mann, 411 

Mansell-Moullin, 278, 280, 

282, 286, 291, 297 
Maragliano, 369 
Marchand, 694 
Marchant, 212 
Markoe, 618 
Marmorek, 848 
Marsh, 696 
Martineau, 67 
Maschka, 290 
Maude, 747 
McCormack, 761 
McCosh, 836,841 
McKenzie, 614 
McPhedran, 614 
Mears, 618, 619 
Melcher, 65 



Melchoir, 827 

Menzel, 627 

Merillat, 414 

Metschnikoff, 40, 106, 107, 

153, 384, 642 
Metsome, 838 
Meyer, 282, 686, 701 
Michaud, 444 
Middledorff, 510 
Mignot, 845 
Mikulicz, 548, 803, 805 
Millat, 612 
Miller, 807, 814 
Mills, 272 
Mitchell, Weir, 84, 85, 86, 87, 

124, 275, 282, 284, 286, 

292, 435, 497, 5o° 
Mixter, 379, 476, 685 
Moebius, 747 
Moller, 29 
Monks, 688 
Monnier, 179 
Monti, 603, 609 
Morax, 817, 835 
Morehouse, 85, 86, 124 
Morgagni, 356 
Morgan, 687 
Morland, 385 
Morrow, 562, 563 
Mosetig-Moorhof, 700, 701, 

790 
Mosler, 576 
Mueller, 502 
Muller, 648 
Miiller, J., 634 
Muller, W., 516, 555 
Mumford, 299 
Murphy, 469, 475 
Murray, 611 
Muscatello, 837, 838 

Nageli, 20 

Nancrede, 132 

Nasse, 238, 704, 713 

Nauwerck, 235, 236 

Neelsen, 339 

Neisser, 50, 64, 801 

Nelaton, 208, 614 

Netter, 836 

Neudorfer, 277 

Neumann, 237, 239, 240 

Newman, 684, 687, 688, 725, 

.753 
Nicaise, 452 
Nicolaier, 54 
Nocard, 59, 486 
Norton, 124 

Obersteiner, 242 

Ogata, 483 

Ogston, 43, 135, 136, 144, 146, 

194, 333, 337, 342, 358 
Oilier, 196, 212, 213 
Ollivier, 418, 419, 420 
Ore, 448 



854 



INDEX OF NAMES. 



Orlowski, 835, 839 

Orth, 259, 674, 675, 677, 694, 

697, 7*9, 720, 721, 75o, 

838 
Ortmann, 65 
Osier, 98, 361, 365, 376, 569, 

57o 
Ostroumoff, 82 
Ott, 305 

Packard, 87, 430, 432 
Page, 293 

Paget, 124, 179, 298, 324, 326, 
613, 671, 738, 758, 768, 

769, 773 
Paltauf, 562 
Panum, 336 
Paracelsus, 356 
Pare, A., 356 
Park, Roswell, 195, 196, 267, 

643, 644, 700, 701 
Partsch, 471, 472, 475 
Pasca, 456 

Passet, 45, 48, 143, 800 
Pasteur, 17, 18, 22, 23,30, 39, 

40, 67, 71, 74, 140, 194, 

336, 357, 35 8 , 455, 4&4» 

465, 467, 468, 478 
Pawlosky, 836 
Pawlowski, 839 
Pawlowsky, 359, 704, 838 
Payne, J. F., 571, 754, 755 
Pearson, 492 
Pelot, 412 
Perron cito, 469 
Peterson, 212 
Petit, 356 
Petit, R., 817 
Petrone, 140 
Petruschky, 848 
Pfeiffer, 595 
Pick, 404, 405 
Piorry, 335, 356 
Pirogoff, 277, 288, 390, 394, 

405, 424 
Pithia, 425, 426 
Podwyssozki, 641 
Poland, 439 
Pommer, 603 
Poncet, 434, 439, 440, 443, 

447, 448, 449, 630 
Ponfick, 76, 469 
Porter, 671, 725, 740 
Post, Abner, 574 
Post, Sarah E., 677 
Potter, 617 
Pouteau, 409, 430 
Power, 644 
Preusse, 492 
Prudden, 509 
Putnam, 461, 615, 747 

Raimbert, 480 
Randolph, 817 
Ranke, 70 



Ranvier, 104, 238, 240, 246, 

444 
Rayer, 71 
Raynaud, 274, 275, 395, 397, 

398, 400 
Recklinghausen, von, 87, 93, 

97, 101, 103, 116,118,241, 

257, 271, 754 
Redard, 297 
Reichel, Z^, 842 
Reichert, 497 
Reid, 660 
Remak, 638 
Reyher, 627 
Reymond, 835 
Ribbert, 143, 149, 360 
Richardson, Anna G., 677 
Richardson, M. H., 49, 669, 

684, 725 
Riedel, 528 
Riedinger, 526 
Riehl, 562 

Rindfleisch, 646, 652, 684 
Rivolta, 455, 469 
Robb, 800 
Roberts, 287 
Robin, 469 

Rochard, 420, 430, 431 
Roger, 594 
Rogivue, 721 

Rokitansky, 357, 577, 634 
Rose, 435, 442 
Rosenbach, 43, 46, 53, 56, 69, 

136, 143, 194, 338, 358, 

359, 3%3, 417, 420, 421, 

425, 442 
Rosenblath, 75, 482 
Rosenstirn, 763 
Rosenthal, 309 
Roser, 208, 537 
Roux, 59, 69, 211, 451, 583, 

848 
Ruge, 673 
Russell, 641 

Salleron, 578, 580 
Samuel, 256, 270 
Sanderson, Burdon, 96, 103, 

113, 119, 120, 122, 357 
Savory, 277, 281, 283, 366, 

377, 378 
Sayre, 541, 547 
Scanzoni, 579 
Schatz, 803 
Schede, 215, 280 
Scheuerlen, 639 
Scheyron, 677 
Schieffendecker, 242 
Schimmelbusch, 139, 270, 

738, 739 
Schloffer, 801 
Schneider, 279 
Schroeder, 672 
Schuchardt, 653 
Schuh, 363, 768 



Schutz, 61, 485, 642, 804 

Schwann, 17 

Scott, 640 

Selmi, 24 

Sendler, 592 

Senn, 70, 216, 254, 553, 555, 

556, 581, 588, 751 
Senner, 173 
Sevestre, 836 
Shakespeare, 56, 103, 106 
Shattock, 644 
Shattuck, 456, 464 
Simmonds, 577 
Simon, John, 115 
Simmourin, 449 
Simpson, Sir Jas., 365 
Sims, Marion, 347 
Sjobring, 641 
Siting, 835 
Smith, Greig, 697 
Smith (Theobald), 847 
Smith, Thomas, 324, 326 
Sokoloff, 623 
Soltmann, 470 
Sonnenburg, 279 
Spallanzani, 17 
Sprouk, 734, 806 
Ssabenejew, Frank, 686 
Stantly, 208 
Stedman, 604, 609 
Steinhaus, 48, 139, 142, 143, 

144, 640, 704 
Sternberg, 25, 31, 355 
Stilly 386, 387,393,399,402, 

404, 405 
Stokes, 836 

Stone, 61, 144, 340, 677, 696 
Stort, 704 
Strassburger, 104 
Straus, 482, 491, 787 
Strieker, 80, 83, 84, 86, 103, 

105, 108 
Stromeyer, 292, 434 
Stuchlen, 840 
Sudan, 276 
Suzor, 454 
Sylvius, 297 
Symonds, 685 

Taguchi, 67 

Targett, 695 

Taylor, 547, 614, 615 

Thieberge, 614 

Thiersch, 189, 224, 636, 650 

Thin, 671 

Thoinot, 18 

Thorn a, 641 

Thompson, 842 

Thompson, Sir Henry, 720, 

752 
Thomson, 419, 423, 427, 750 
Thornbury, 412 
Thorndike, 693 
Tillmans, 381, 382, 383, 385, 

394, 397, 401, 405 



Tizzoni, 451, 46S, 616 
Torek, 729 
Trau be, 30S, 309 
Travel, 800 

Travels, 277, 286, 296, 435 
Tricomi, 70 

Trousseau, 39S, 402, 446 
Tscherning, 510 

Uffreduzzi, 70 

Ullmann, 195, 197, 207, 210 

Van Arsdale, 205, 212 

Van I Jure 11, 119, 122 

Van Harlingen, 560 

Vanlair, 243 

Vaughn, 339, 342 

Veit, 673 

Velpeau, 356, 403 

Vernet, 123 

Verneuil, 436, 444, 482, 639, 

.755 

\ etiesen, 581 

Viering. 234 

Vignal, 595 

Villemin, 56, 504 

Vincent, 289 

Virchow, 97, 101, 1 18, 126, 
218, 357, 485, 578, 612, 
613, 633, 634, 635, 636, 
637, 640, 703, 707, 717, 
729, 754, 760, 765, 767, 
769,874,881 

Vogt, 243 

Volkmann, 166, 205, 208, 



INDEX OF NAMES. 



212, 390, 392, 400, 514, 
516, 520, 531, 532, 536, 

539, 543, 566, 567, 5*5, 
588, 589, 630, 659, 060, 
668 

Vollert, 630 

Von Hacker, 686 

Von Winckel, 836, 840 

Vulpian, 79 

Wagner, 734, 838 
Wall, 497 

Wallenberg, 679 

Waller, 86, 238 

Wallick, 841 

Walthard, 842 

Walton, 309 

Warren, J. C, 634, 718 

Warren, M., 655, 718 

Washburn, 839 

Wasserman, 726 

Waterhouse, 838 

Watson, 695, 696, 752 

Weber, 314 

Weber, C. O., 116 

Weber, O. 421 

Wegner, 617, 781 

Wehr, 643 

Weichselbaum, 579, 622 

Weigert, 106, 257 

Weil, 652 

Weir, 690 

Welch, 138, 143, 571, 688, 

800, 801, 803 
Wells, Spencer, 572 



855 

Wette, 747 

White, J. C, 406, 641, 652 

Whitaker, 483 

Whitehead, 682, 683 

Wickham, 641, 671, 672, 71 1 

Wiggleworth, 139 

Wight, 790 

Williams, 94, 673 

Williams, J. L., 815 

Winckel, 573, 579, 600, 602, 

720 
Winiwarter, 187, 662, 668, 

698, 709, 710, 711, 771, 

773,781, 782 
Witzel, 686 
Wolff, 637 
Wolfler, 743, 744 
Wood. 40, 305 
Wood, H. C, 313 
Woodhead, 642 
Wright, 836 
Wyssokowitsch, 42, 360 

Yandell,437, 441, 443, 447, 

448, 450 
Yarrow, 495, 497 

Zagari, 595, 596 

Zahn, 122, 361 

Zeigler, 104, 106, 156, 218, 
219, 605, 610, 612, 616, 
624, 704, 763, 776, 780 

Zeisler, 561, 562 

Zenker, 683 

Ziemssen, 643, 652, 755 



INDEX 



Abscess, 156, 157 
atheromatous, 259 
callosities of the hand the 

starting-points of, 1 71 
drainage in, 165 
fluctuation in, 158 
formation, 147 
lung, experimental, 145 
psoas, 525 

retropharyngeal, 525 
shirt-stud, 168 
tubercular, membrane of, 

520 
wall of, 157 
Abscess-formation, bacteria 
of, 789 
in osteomyelitis, 198 
Abscesses, cold, 519 
treatment, 548 
mammary, 165 
metastatic, 362 
of heart, 376 
of kidneys, 376 
miliary, in pyaemia, 363 
palmar, course of pus bur- 
rowing in, 171 
Absorption in bone-tuberculo- 
sis, 522 
callus, 249 
Acetabulum wandering, 536 
Acid, carbolic, in asepsis, 789 
causing fever, 323 
in erysipelas, 406 
in gangrene, 275 
in treatment of boils, 174 
nitric, in hospital gangrene, 

431 
method for detection of 
cancer, 672 
Acromegaly, 615 

relation of thymus gland to, 
615 
Actinomyces, 76 
cultures, 470 
staining, 77, 809 
Actinomycosis, 469 
history, 469 
prognosis, 475 
symptoms, 471 
treatment, 475 
Actinomycosis, appearances 
of, post-mortem, 471 
in cattle, 476 



Actinomycosis, deposits in, 
metastatic, 473 

expectorations in, 474 

infection through the intes- 
tinal tract, 474 
through the respiratory 
tract, 474 

lungs in, condition of, 474 
in man, 471 

of mouth, 472 

progress of the disease, 472 

of skin, 475 

transmission, 470 
Active hyperemia (see Hy- 

pe?-cemia). 
Actol, 803 

Adenitis, tubercular treatment, 
588 

of neck, tuberculous, 586 
Adeno-carcinoma of kidney, 
697 

of rectum, 691 

of uterus, 674 
Adenoma, 737 

of breast, 738 

classification of, 738 

cysto-, of breast, 739 

fibro-, of breast, 738 

of kidney, 741 

sebaceum, 740 

of sweat-glands, 650, 740 

of testis, 742 
Aerophobia, 458 
Agar-agar, 34 
Air and sepsis, 786 
Air, bacteria in the, 786 

embolism, 296 
Air-passages, sarcoma of, 725 
Alcohol in septicaemia, 354 
Ammonaemia, 346 
Amputation in gangrene, 263, 

433 
in osteomyelitis, 21 1 
Amputation- stumps, neuroma 

of, 773 
Amyloid degeneration, 329 
Anaesthesia in rabies, 454 
Anal canal, sterilization of, 830 
Aneurism, cirsoid, 780 
Aneurisma racemosum, 780 
Angioma, 777 

cavernous, 779 

venosum, 780 



Angio-myoma, 776 
-neurology, 79 
-sarcoma, 708, 719 
of kidney, 719 
Animal-inoculation in bacteri- 
ological examinations, 
788 
Animals, rabies in, 453 
Ankylosis, 625 

cartilage, destruction in, 

625, 626 
experimental, 627 
in joint-tuberculosis, 534 
Anthrax, 477, 484 

convulsions, tetanic, 481 
diagnosis, 481 
epidemics, 477 
incubation, 479 
infection, method of, 478 
prognosis, 482 
treatment, 483 
Anthrax, appearances of, in 
man, 480 
pathological, 481 
post-mortem, 482 
bacillus, 70 
in catgut, 798 
distribution of, in man, 

482 
pyocyaneus, action of, 483 
spores, 72, 477 
Antiseptics, 784, 801 

of tooth-filling, 815 
Antistreptococcus serum, 848 
Arsenic, bromide of, in can- 
cer, 700 
Arteries, healing of, 250 
ligature of, 251, 254, 255 
callus after, 251 
organization of thrombus 

after, 252 
role of thrombus after, 254 
nutrient, in osteomyelitis, 
197 
Arthrectomy, 554 
Arthritis, chronic dry, 623 
deformans, 620 

eburnation of bone in, 

622 
treatment, 624 
osteomyelitis followed by 
acute suppurative, 205 
Arthropathy, spinal, 624 

857 



INDEX. 



Arthrotomy, 553 

Ascites, hypersemia following 

tapping for, 87 
Aseptic fever (see Fever). 
Asphyxia, local, 272, 274 
Atrophy, bone, in joint-tuber- 
culosis, 534 

neuro-paralytic, 6 II 

senile, 609 
Auto-clave, t>Z 

-transfusion, 299 

Bacilli, anthrax, in man, 482 
in submiliary tubercle, 506 
of tetanus in garden soil, 436 
of tuberculosis, demonstra- 
tion of, 56, 505 
staining sputa for the, 57 | 
of typhoid, a cause of osteo- 
myelitis, 196 
Bacillus anthracis, elimination 

. of ' 75 
coli communis, 48 

distinguished from ba- 
cillus typhosus, 49 

infection, 73 

lactis aerogenes, 828 

mallei, 61 

mucosus capsulans, 845 

passage through the pla- 
centa. 75 

pyocyaneus, 47, 801 

action upon anthrax, 483 

pyogenes fcetidus, 48 

spores, 72, 477 

typhosus in cystitis, 827 

vaccination against, 74 
Bacillus, anthrax, cultures of, 
methods of obtaining, 

55 
growth, 59 
Bacillus of cancer, 639 
of glanders, 61 

in mouth, 815 
of leprosy, 64 
of malignant oedema, 67, 

163 
of pseudo-oedema, 69 
of syphilis, 65 
of tetanus, 54, 435 
where found, 436 
of tuberculosis, 56 

in cystitis, 827 
of xerosis, 818 
staining methods, 57 

Koch's demonstration 

of, 5°5 
Lustgarten's, 66 
Ziehl*s, 57 
Bacteria, 18 

action in disease, 37 

in the living body, 38 
aerobic, 23 
anearobic, 23 
in the blood, 144, 359 



Bacteria, capsule, 19 

cell-structure, 19 

chromogenic, 19 

classification, 18 

color-producing, 19 

culture-media, 33 
solid, 31 

culture, plate, 36 
stab, 35 

destruction of, by leuco- 
cytes, 106 

dilution of, 36 

dose, 137 

elimination of, from the 
system, 144 

examination methods, 25 

facultative, 23 

in aseptic fever, 323 

in suppurative fever, 329 

fever without, 315 

forms, 19 

in gangrene, 266, 267 

in garden soil, 69 

gas-formation, 24 

growth favored by state of 
the blood, 150 
favored by strong anti- 
septics, 150 

history of, 17 
in the body, 143 

infection, toxic, 39 

can inflammation exist with- 
out ? 122 

causing inflammation, 121 

in infective inflammation, 

l 35 

inflammation due to, 139 

toxic products, 138 

types of, 135, 136 
immunity, 39, 152 
inoculation, protective, 39 
kidneys as eliminators of, 

144 
light on, influence of, 23 
morphology of, 18 
motility, 19 

method of study, 26 
movements of, 19 
multiplication of, 22 
in noma, 270 

numbers of, necessary to 
cause suppuration, 137 
in osteomyelitis, 194 
of cystitis, 826 
of eye, 818 
of male urethra, 824 
of meatus urinarius, 824 
of mouth, 814 
oxygen on, influence of, 23 
pathogenic, 42 

Koch's laws on, 42 
peptonizing action of, a 
cause of suppuration, 

155 
pigment-formation, 24 



Bacteria, preparation, hanging- 
drop, 26 
products of, chemical, 23, 

.138 
pus without, 140 
in pyaemia, 359 
pyogenic, 143 
in man, 138 
relation to aniline dyes, 18 
removal of fat from speci- 
men containing, 29 
reproduction, 20 
respiratory organs in elimin- 
ation of, 145 
saprogenic, 22 
saprophytic, 22 
in scrofula, 594 
in septicaemia, 337, 338 
specimen, preparation of, 

28 
spore-formation, 20 

staining, 29 
staining, double, 27 
color-picture, 25 
methods, 26 
structure-picture, 25 
sterilization, dry heat, 31 

steam, 31 
in suppuration, 137, 155 

frequency, 139 
in temperature, 22 
in text-books, 25 
tissue containing, prepara- 
tion of a, 30 
Bacteria, micrococcus pyog- 
enes tenuis, 46 
tetragenus, 48 
staphylococcus albus, 45 
cereus, 45 
citreus, 45 
erysipelatis, 53 
flavus, 45 

pyogenes aureus, 43 
viridis flavescens, 45 
streptococcus erysipelatis,53 
pyogenes, 46 
Bacteria : bacillus anthracis, 
70 
coli communis, 48 
foetidus, 48 

of malignant oedema, 67 
mallei, 61 
pseudo-oedema, 69 
tuberculosis, 56 
Bacteriological examinations, 

788 
Bacteriology of ear, 819 
of eye, 816 
of gall-bladder, 842 
of genito-urinary system, 

822 
of mouth, 812 
of nose, 820 
of peritonitis, 834 
of skin, 800 



INDEX. 



859 



Bacterium coli commune in 

cystitis, 826 
Bacterraria, S2$, 826 
Balsam, xylol, 29 
Bath, cold, reaction from, 304 
in treatment of inflamma- 
tion, 133 
vapor, in tetanus, 450 
Bed -sore, 271 

Benign tumors (see Tumors). 
Bichloride of mercury, 802 
Big-jaw, 469 
Black tongue, 397 
Bladder, bacterial invasion of, 
823 
cancer of, 694 
villous, 694 
disinfection of, 830 
distended, catheterization 

of, in hyperemia, 87 
extirpation of, 696 
papilloma, 752 
routes of infection by bac- 
teria, 828 
sarcoma of, 719 
sterilization of, 830 
tuberculosis of, in women, 

579 
Blood, buffy coat of, 100 
circulating, toxic products 

in, 138 
coagulation of, 100 
color of, in inflammation, 

96,97 
corpuscles of, third, 98 
in fever, 312 
bacterial growth favored by 

the state of, 1 50 
in lymphoma, 733 
pus in, 363 

in pyaemia, 363 
in pyaemia, 371 
slowing of, 89 
sugar of, 787 
Blood-clot, absorption of, fever 
caused by, 100, 321 
in after-treatment of osteo- 
myelitis, 215 
organization, 231 
in tendon repair, 233 
Blood-corpuscle, third, 98 
Blood-corpuscles, white, dia- 
pedesis, 93 
increase of, in inflamma- 
tion, 99 
Blood-examination, 786 

dry, 787 
Blood-flow, increased, in ac- 
tive hypersemia, 80 
Bloodletting, 133 
Blood-pigment in ulcer, 184 
Blood-plaques, 99 
in pyaemia, 361 
Blood-serum as a culture-me- 
dium, 788 



Blood-serum, bactericidal ac- 
tion, 41 
in tetanus, 451 
in therapy, 153 
therapy in rabies, 803 
Blood-vessels in inflammation, 
92 
action of, 92 
dilatation of, 95 
escape of fluids from, 108 
small budding growth from, 
229 
Body exposed to cold, 303 
to constant heat, 303 
temperature, inequalities in, 
302 
Boil, core of a, 172 
Boiling instruments for sterili- 
zation, 795 
Boils, treatment of, carbolic 
acid in, 174 
prophylactic, 174 
sulphide of calcium in, 

175 
Bone atrophy in joint-tubercu- 
losis, 534 
neuro-paralytic, 61 1 
senile, 609 
callus, 245, 246 
intermediate, 245 
ossification of, 247 
chemical changes in, in 

osteomalacia, 599 
chips in after-treatment of 

osteomyelitis, 216 
diseases of, 597 
eburnation of, 208 

in arthritis deformans,62i 
fistula after osteomyelitis, 

214 
fracture of, callus after, 245 
changes following histo- 
logical, 246 
healing of, 244 
hyperplasia of, 61 2 
internal callus, 245 
lime -salts of, absorbed in 

osteomalacia, 597 
marrow, changes in, patho- 
logical, 616 
necrosed, solvent action of 
pus on, 200 
spontaneous fracture from, 
200 
non-union, 250 
osteoblasts, 246 
repair, 245 

absorption of callus, 249 
hyaline cartilage in, 249 
reproduction, 246 
sarcoma of, 712 

central round-cell, 714 
central spindle-cell of, 713 
spontaneous fracture in, 
7H 



Bone, sequestra of, in osteo- 
myelitis, 199 
tissue, destruction of, in hip- 
joint disease, 536 
tuberculosis (see Tubercu- 
losis). 
tumors, myeloid, 713 
typhoid, 193 
Bones affected in osteoporosis, 
610 
in ostitis deformans, 613 
in rickets, 608 
chemical changes in, in 

ostitis deformans, 599 
of cranium in sarcoma, 717 
flat, in osteomyelitis, 203 
medullary tissue of, in os- 
teomalacia, 598 
in pyaemia, 377 
Boric acid, 803, 834 
Bottles, hot-water, burns from, 

272 
Brain, nerve-tissue repair in, 
242 
in pyaemia, 376 
sarcoma of, 729 
Breast, adenoma of, 738 
cancer of, 662 
colloid, 665 
heredity in, 663 
medullary, 664 
metastasis in, 667 
pain in, 666 
scirrhous, 664 
traumatism in, 663 
cysto-adenoma of, 739 
fibro-adenoma of, 738 
hypertrophy of, 740 
pigeon, 607 
sarcoma of, 723 
malignancy, 724 
Breath in pyaemia, odor of, 

. 369 
Bromide of arsenic in cancer, 

700 
Bromine in hospital gangrene, 

432 
Brownian movement, 19 
Budding growth from small 
blood-vessels, 229 
of muscle-fibres, 237 
Buffy coat of blood, 100 
Burns from hot-water bottles, 
271 
shock from, 290 

Cachexia, cancerous, 646 
Calabar bean in tetanus, 448 
Calcium, sulphide of, 175 
Callus absorption, 249 

after fracture of bone, 245 

ligature of an artery, 251 
bone, 245, 246 
intermediate, 245 
ossification of, 247 



86o 



INDEX. 



Canals, plasma, in capillary 

development, 230 
Cancer, 638 
bacillus of, 639 
cells, 644 

as protozoa, 640 
chimney-sweeps', 658 
in cicatrix, 660 
coccidium in, 640 
detection of, nitric-acid 

method for, 672 
diagnosis of, extent of, 672 
distribution, 643 
en cuirasse, 667 
etiology of, 639 
extension through lymphat- 
ics, 645 
infiltration in, round-cell, 

651 ; 

lymphatic system in, 645 

medication in, 698 

melanotic, 648 

origin of, epithelial, 638 

pearls in, epithelial, 649 

protozoa in, 640 

scirrhous, 647, 664 

spider, 777 

stricture of rectum from, 

692 
treatment, therapeutic, 701 

bromide of arsenic in, 700 

Chian turpentine in, 701 

pyoktanin in, 700 
Cancer of bladder, villous, 
694 
of breast, 662 

classification, 663 

colloid, 665 

diagnosis, 670 

duration of life of, 669 

heredity, 663 

history of, clinical, 666 

locality, 663 

medullary. 664 

metastasis in, 668 

operation, mortality after, 
669 

Paget's disease of the 
nipple, 671 

pain in, 666 

scirrhous, 664 

traumatism in, 663 
of face, 652 

seat, 654 

superficial, 653 

ulcerations in, 654 
of hand, 656 

metastasis in, 656 
of intestines, 689 
of kidney, 696 
of labia, 657 t 

of larynx, 686 
of lip, metastasis in, 656 

smoking a cause, 655 

treatment, 661 



Cancer of oesophagus, 684 
treatment, 685 
of penis, 657 

treatment, 661 
of rectum, 690 

Kraske's operation, 693 
relieved by erysipelas,398 
of scrotum, 658 

tar and paraffin in, 659 
of skin, 652 

deep-seated, 649 
superficial, 650 
treatment, 660 
of stomach, 688 
of testicle, 698 
of tongue, 677 
beginning of, 680 
diagnosis, 682 
leucoma an early stage 

of, 679 
metastasis, 680 
operations for, 682 
of uterus, 672 
body, 674 
cervical canal, 674 
diagnosis, 670 
hemorrhage early symp- 
tom of, 676 
heredity in, 673 
hydrometra in, 675 
metastasis, 675 
pregnancy a cause of, 673 
treatment, 677 
vaginal portion, 673 
Cancroin, 699 
Cancrum oris, 270 
Capillaries, distention of, in 

inflammation, 92 
Carbolic acid (see Acid). 
as an antiseptic, 802 
Carbuncle, appearances, cause 
of crater-like, 1 77 
columnar adiposse in 176 
condition, gangrenous, 181 
constitutional diseases pre- 
disposing to, 175 
diabetes predisposing to, 

. 75 
excision, total, 181 
fascia limiting extent of, 177 
hair-follicles in, 176 
inflammation of deeper tis- 
sues, 177 
of lip, 179 
meningitis from, 180 
necrosis in, coagulation, 179 
peculiarities,anatomical, 1 76 
size, 179 

swelling, features of, 177 
symptoms, constitutional, 

179 
thrombosis of facial vein in, 

180 
treatment, 180 
radical. 181 



Carcinoma, 638 
classification, 647 
in the granulations of osteo- 
myelitis, 208 
of skin, 648 
Carcinosis, acute miliary, 646 
Caries, 523 

of the ribs, 525 
Caries sicca, 531 

in shoulder-joint tubercu- 
losis, 538 
Cartilage in ankylosis, destruc- 
tion of, 625 
cells in rickets, 605 
epiphyseal, in osteomyelitis, 

196, 199, 201 
hyaline, in bone-repair, 249 
in the joint, 767 
in tuberculosis, ulceration 

of, 531 

Castration in tuberculosis of 

testicle, 580 
Catgut, sterilization of, 806 
Cattle, actinomycosis in, 476 
Cell-division, indirect, 218 
Cell-infiltration, inflammation 
dependent on the 
amount of irritation, 
108 
Cell-proliferation, ioi, 218 
Cells, amoeboid movement of, 
101 
cancer, 644 

as protozoa, 643 
cartilage, in rickets, 605 
of cord in shock, 285 
embryonal, 220 
epithelioid, in granulation 

tissue, 229 
in tuberculosis, 506 
formative, 220 
giant-, sarcoma, 706 
muscular, proliferation in 

repair of muscle, 236 
plasma, 220 

slumbering, in tendon re- 
pair, 234 
spindle-, in granulation tis- 
sue, 227 
tissue-, proliferation of, in 

inflammation, 104 
wandering, 93, 101 
in inflammation, 101 
Cephalalgia in hydrophobia, 

458 
Chemical sterilization of the 

skin, 802 
Chemotaxis, 152 
negative, 153 
positive, 153 
Chilblains mistaken for sym- 
metrical gangrene, 273 
Children, surgical scarlet fever 
frequent in, 324 
scrofulous, 594 



INDEX. 



86 1 



Chill, 307 

of fever, 307 
Chills in pyaemia, 366 
Chloral in tetanus, 44S 

Chlorides in urine, 793 
Chlorine as a disinfectant, 

803 
Chloroform balsam, 29 

in tetanus, 449 
Chlorophyll, 22 
Chondroma, 765 

osteoid, 765, 768 

of parotid gland, 768 
Chondrosarcoma, 716 
Cicatrices, cancer developing 

in, 660 
Cicatrix, arterial, after ligature, 

253 
tendon, 234 
Cilia, 19 

Circulation in inflammation, 92 
Circumcision, rite of, trans- 
mission of tuberculosis 
in, 510 
Cirrhosis, 127 
Civil War, hospital gangrene 

in, 410 
Cleanliness in wound-treat- 
ment, 808 
Clefts, branchial, 751 
" Clump-theory," 845 
Coagulation, blood, 1 00 

of fibrous exudation, 113 
Coagulation-necrosis, 257 
in carbuncle, 179 
after infective thrombi, 

147, 148 
after suppuration, 156 
Cocci, erysipelas, action on 
sarcoma of, 735 
pyogenic, experimental in- 
oculation in man, 139 
in osteomyelitis, 194 
Coccidium in cancer, 640 
Cold, action of, 91 
catching, 122, 303 
reaction from, 304 
Cold bath, reaction from, 304 
in treatment of inflam- 
mation, 133 
Collapse, 277 

Color of blood in inflamma- 
tion, 97 
of an inflamed part, ill 
Color picture, 25 
Columnae adiposae in car- 
buncle, 176 
Complexion in keratosis, 652 
Condenser, Abbe, 25 
Connective tissue, cancer, 665 

formation, 221 
Convulsions, tetanic, in an- ! 

thrax, 481 
Cornea, leucocytes in, 102 
structure, 102 



Corpuscle, blood- (see Blood- 
corpuscles). 

Corpuscles, corneal, 102 
white, migration of, 93 

Corrosive sublimate, 802 

as a genito-urinary germi- 
cide, 833 

Cotton gloves, 805 

Cover-glass preparations, 26 

Cranio-sclerosis, 612 

Craniotabes, 606 

Cranium, bones of, sarcoma, 
717 

Cretinism, 746 

Crimean War, hospital gan- 
grene in, 410 

Croton oil producing suppura- 
tion, 140 

Culture media, 31 

Culture, plate, 36 

Curetting vein of sinus in 
pyaemia, 379 

Cushing, 845 

Cylindroma, 703 

Cystitis, bacteria of, 826 
reaction of urine in, 824 
role of bacteria in, 823 

Cysto-adenoma of the breast, 

739 
Cystoma, 748 
Cysts, dermoid, of the ovary, 

.749 
ovarian, 748 
of parovarium, 749 

Daughter-star, karyokine- 

sis, 219 
Death-rate of hydrophobia, 

467 
Deaths from snakes in India, 

495 

Debility favoring rickets, 603 

Decomposition, 22 

Decubitus, ulcerating, in hip 
disease, 536 

Deformities in ostitis de- 
formans, 601 
following rickets, 606 

Deglutition in hydrophobia, 

457. 
Dermatolysis, 757 

Dermoids, ovarian, 749 

Diabetes predisposing to car- 
buncle, 175 

Diapedesis of white blood- 
corpuscles, 93 

Diarrhoea in septicaemia, 347 

Diphtheria, relation of hospital 
gangrene to, 420 

Diplobacillus of Friedlander, 
828 
of Morax and Axenfeld, 818 

Diplococci, 21 

Diplococcus ureae liquefaciens, 
827 



Disease, bacterial action in, 37 
germ theory of, 17 
Graves's, 747 
hip-joint, 514, 535, 536 
Hodgkin's, 730 
Paget's, of the nipple, 671 

psorosperms in, 672 
Pott's, 513, 523,524 
wool-sorters', 76, 479 
zymotic, 17 
Diseases of bone, 597 

constitutional, predisposing 

to carbuncle, 175 
infectious, cause of ulcer, 

182 
produced by bacterial prod- 
ucts, 37 
Disinfectants, in septicaemia, 
354, 802 
J Disinfection of surgeon's 
hands, 805 
Dislocation resulting from 
osteomyelitis, 208 
spontaneous, 533 
Distention, capillary, 92 
j Drainage in abscesses, 166 

postural, 840 
1 Dressings for wounds, 811 
sterilization of, 806 
Dry blood, examination of, 787 
Dryness of wounds, 810 
I Dumb rabies, 453, 455 
Dyes, aniline, 26 
acid, 27 

bacterial relation to, 18 
basic, 27 

Ear, bacteriology of, 819 

sterilization of, 819 
Earthy- worm dissemination of 
anthrax spores, theory 
of, 478 
Eburnation, 517 
of bone, 208 

in arthritis deformans, 
622 
Ecchymosis, punctiform, no 
Elbow-joint tuberculosis, 539 
1 Emaciation in suppurative 
fever, 328 
Embolism, 262 
air, 298 
fat, 204, 296 
Emulsion, Krause's, in treat- 
ment of fistula, 191 
Enchondroma, 765 

hyaline, 768 
Endarteritis deformans, 259 
arterial repair, compensa- 
tory, 255 
obliterative, 258 
Endocarditis, 347 
in osteomyelitis, 204 
from experimental pyaemia, 
360 



862 



INDEX. 



Endocarditis in pyaemia, 360 

ulcerating, 363, 365, 372 
Endothelioma, 648 
Enemata in shock, 299 
Epidemic goitre, 746 
Epidemics, erysipelas, 381 
of furunculosis, 173 
of hospital gangrene, atmo- 
spheric conditions af- 
fecting, 420 
of glanders, 493 
of tetanus, 437 
Epiphyseal cartilage in osteo- 
myelitis, 199, 201 
separation, 201 
Epithelioma, 647 
Epulis, 716 
Ergotism, 271 

Eruption in septicaemia, 347 
Erysipelas, 381-408 
prognosis, 402 
symptoms, 388 
cerebral, 440 
following, 392 
treatment, 403 

carbolic acid in, 406 
iron in, use of, 404 
of wound in, 407 
Erysipelas, action, curative, 
390 
cancer of rectum relieved 

b y> 398 

on malignant growths, 

734 

cause of constitutional dis- 
turbance, 384, 391 

cocci, action on sarcoma of, 

435 

a complication in hospital 
gangrene, 427 

condition of the skin in, 
pathological, 398 

conditions predisposing to, 
atmospheric, 387 

contagiousness of, 385 

disturbance, gastric, 400 

duration of, 390 

of epidermis, 381 

facial, 394 

lachrymal ducts a start- 
ing-point, 395 ( 
meningitis following, 396 

puerperal fever and, 386 

habitual, 390 

hemorrhage in, 399 

inflammation of skin in, 
388 

inflammations, malignant, 

393 
influence, curative, 400 
inoculation experiments, 382 
of mucous membranes, 397 
neonatorum, 388, 396 
oedema of glottis in, 398 
patient, isolation of, 408 



Erysipelas, phagocytosis, 107 

phlegmonous, 392 

relapse, 408 

spread of, tendency, 389 

streptococci in, 399 

entrance, point of, 386 
seat of, 384 

streptococcus of, 382 

and pyogenes streptococcus, 
identity of, 383 

synovitis following, 392 

following vaccination, 385 

vesicles in, 389 

virus, ^82 

wound, condition of, 390 
Erythema, toxic, 324 
Erythromelalgia, 87, 275 
Euphoria, 348 

Exanthemata, metastatic in- 
flammation of joints in, 

543 
Excision, treatment of tendon- 
sheath tuberculosis by, 

593 
Exostosis, 769 

ivory, 769 

submanual, 770 
Expectorations in actinomyco- 
sis, 474 
Exudation, 109 

cause of, explanation, 113 

in inflammation, 94 

inflammatory, uses of, 1 13 
Eye, bacteriology of, 816 

Face, cancer of (see Cancer). 

erysipelas of the, 394 

tuberculosis of, 528 
Fainting, 296 

Fallopian tubes a source of 
tubercular peritonitis, 

569 
tuberculosis of, 573 
Farcy, 485-494 
Farcy-buds, 491 
Fascia limiting extent of car- 
buncle, 177 
Fat-embolism, 204, 296 
Fat in staining bacteria, the 
removal of, 29 
in pus of osteomyelitis, 
204 
Fatigue, meaning of, 283 
Fat-neck, 761 
Feces, examination of, 795 
Felon, 167 

cutaneous form, 168 
incision in case of, 170 
character of pain diagnostic 

as to form, 169 
periosteal form, 169 
reaching to the tendon- 
sheath, 169 
treatment, 170 
Fermentation, 23 



Fermentation, theory of Pas- 
teur, 23 
Fever, absorption of blood- 
clot causing, 100, 321 
antiseptics causing, 323 
aseptic, 319 

bacteria in, 323 
chemicals causing, 323 
temperature, 320 
tension from suture caus- 
ing, 3 2 3 
blood-changes in, 312 
from carbolic acid, 323 
causes of, 314 
the chill of, 307 
defervescence, 308 
defined, 315 

due to diminished heat- 
elimination, 308 
increased heat - produc- 
tion, 309 
fastigium, 308 
heat-production in, causes 
of, 311 
hectic, in tuberculosis, 519 
iodoform causing, 323 
nerve-action, 313 
neurotic theory of, 314 
puerperal, and erysipelas, 

386 
scarlet, surgical, 323, 324 
toxic erythema, 324 
origin in surgical cases, 
323, 326 
secondary, 327 
splenic, 477 
stage of invasion, 308 
suppurative, 327 

amyloid degeneration, 

932_ 
bacteria in, 329 
emaciation in, 328 
leucocytes in, 329 
operations in, 330 
temperature in, 328 
treatment, 330 
symptoms of, 307 
traumatic, cleaning of the 
wound, 318 
gangrene, 265 
temperature, 317 
urea, excretion, 312 
urethral, 124, 331 

nerve-action in, ^t, 
without bacteria, 315 
Fevers, surgical, 316-333 
Fibrin formation in inflamma- 
tion, 108 
Fibro-adenoma of the breast, 

738 

-glioma, 763 

-lipoma, 761 

-myoma, 775 
Fibro-blasts, 220, 224 
Fibroma, 753 



INDEX. 



863 



Fibroma molluscum, 754 
multiple, 754 
nasopharyngeal, 759 
papillary, intracanalicular, 

738 

of skin, multiple, 754 
soft, 757 
Field of operation, sterilization 

of, 804 
Fistula in ano, 567 
Fistula, bone, after osteomye- 
litis, 214 
defined, 190 
treatment, 191 

Krause's emulsion in, 191 
Fontanelles in rickets, 606 
Foreign bodies, location of, by 

x-rays, 797 
Formaldehyde, 803 
Formalin, 803, 814 

as a disinfectant, 805 
Formalin-gelatin, 803 
Fracture of bone, callus after, 

245 

histological changes fol- 
lowing, 246 
spontaneous, 207 

from bone-necrosis, 200 
in bone sarcoma, 714 
Fractures, x-rays in, 797 
Fragilitas ossium, 610 
Frog's tongue, passive hyper- 

semia, study of, 89 
Frost-bite a cause of gan- 
grene, 268 
treatment of, 269 
Furuncle, 172 
Furunculosis, 1 74 
epidemics of, 173 

Gall-bladder, bacteriology 
of, 842 
typhoid invasion of, 843 
Gall-stones, relation of bac- 
teria to, 844 
Ganglia, perivascular, in ac- 
tive hypersemia, 82 
paralysis of, 87 
Gangrene, 256-276 

ainhum terminating in, 275 
amputation in, 263, 433 
bacteria in, 266, 267 
bed-sore, 271 
carbolic, 275 
causes of, 256 

arterial changes, 258 
arterial injury, 265 
extravasation of urine, 

270 
mechanical action, 256 
putrefactive changes, 266 
vaso-motor disturbance, 
274 
demarcation in, line of, 260 
diabetic, 264 



Gangrene, diphtheritic form 
of, 421 
emphysema, 267 

tibial artery, 262 
ergotism, 271 
foudroyante, 267, 394 
frost-bite a cause of, 268 
fulminating, 267 
hospital, 409-433 
amputation in, 433 
at Andersonville, 411 
atmospheric conditions 
affecting epidemics of, 
420 
in the Civil War, 410 
contagiousness, 418 
in the Crimean War, 410 
diagnosis, 429 
discharge in, 425 
erysipelas a complication, 

427 
forms of, 420-422 
hemorrhage in, 425 
incubation of, period, 420 
joints as affected by, 426 
micro-organisms in, 415 
mortality, 430 
non-infection of wounds 

in same person, 419 
post-mortem appearances, 

429 
prognosis, 430 
pulpy, 424 

relation to diphtheria, 420 
study of, microscopic, 

416 
synonyms, 409 
temperature in, 426 
treatment, 430 
bromine in, 432 
carbolic acid in, 433 
nitric acid in, 431 
ulcerating, 423, 424 
infection in, bacterial, 266, 

267 
intoxication in, septic, 428 
moist, 260 
mummification, 260 
neuropathic, 256 
noma, 270 
senile, 260 
symmetrical, 272 

chilblains mistaken for, 

273 
symptoms of, 262 
traumatic, 265 
ulceration in, phagedenic, 
424 
Garden soil, bacilli of tetanus 

in, 436 
Gastrostomy, 685 
Gelatin, 34 

Generation, spontaneous, 17 

Genitals, routes of infection 

by bacteria, 828 



Genito-urinary system, bacte- 
riology of, 822 
tuberculosis, 573 
Germ-theory of disease, 17 
Gentian-violet, 27 
Giant-cell formation, 219 
Giant-cells as phagocytes, 
107 
in sarcoma, 706 
in tuberculosis, 59, 505 
Gigantism, 615 

Gland, parotid, chondroma of, 
768 
thymus, relation of, to acro- 
megaly, 615 
Gland-ducts, sudoriparous, the 
entrance-gates of infec- 
tion, 172 
Glanders, 485-494 
acute, 487 
bacillus of, 61 
changes in, pathological, 

489 

epidemics, 493 

laws concerning, 493 

infection, method of, 486 

in man, 487 

mucous membrane in, 488 

nodules in, 490 

prognosis, 491 

transmission in utero, 486 
Glands, lymphatic, prognosis 
of tuberculosis of, 588 

mesenteric, tuberculosis of, 
570 

scrofulous, 585 
Glioma, 763 
Gliosarcoma, 707 
Glottis, oedema of, in erysipe- 
las, 398 
Gloves, operating, 805 
Glutol, 803 
Goitre, 743 

epidemic, 746 

exophthalmic, 747 
Gonococcus, 50 

in cystitis, 828 

diagnosis of, 52 

in endocarditic and meta- 
static inflammation, 

52 
growth, 51 

Gonorrhoea a factor in spread 
of tuberculosis, 575 

Goose-flesh, 303 

Gram's method, 27 

Granulation, healing by, 225 
tissue, 157, 226, 228 

Granulations, carcinoma in 
the, osteomyelitis, 208 

Graves's disease, 747 

Grawitz, slumbering-cell the- 
ory, 105 

Greeks, sepsis and asepsis of, 
785 



864 



INDEX. 



Hair-follicles in carbuncle, 

176 
Hand, callosities, the starting- 
points of abscess, 171 
cancer of, 656 

metastasis in, 656 
Head tetanus, 441 

mortality of, 442 
Healing by first intention, 222 
by granulation, 225 
by second intention, 225 
by third intention, 232 
Heart, abscesses of, metastatic, 

in pyaemia, 376 
Heat-equilibrium, 302 
Heat, metabolism a source of, 

3°4 
as a symptom of inflamma- 
tion, 115 
in the treatment of inflam- 
mation, 133 
Heat-production from glandu- 
lar activity, 304 
in fever, causes, 311 
in health, 304 
in inflamed part, 115 
through the nerves, 305 
Hematuria, 791 
Hemorrhage in erysipelas, 399 
in hospital gangrene, 425 
causing shock, 289 
symptoms of, 286, 296 
an early symptom of cancer 
of the uterus, 676 
Heredity in cancer of breast, 
663 
of uterus, 673 
of tuberculosis, 508 
Herpes due to trophic nerves, 

123 
Hip disease, decubitus in, ul- 
cerating, 536 
Hip-joint disease, 514, 535, 

536 . 

destruction of bone tissue, 

.536 . 

Hodgkin's disease, 730 
Hospital gangrene (see Gan- 
grene). 
table for patients in shock, 
298 
Hot water as stimulant of the 
constrictor nerves, 88 
bottles, burns from, 272 
Hydrocele of neck, 751 
Hydrometra in cancer of ute- 
rus, 675 
Hydrophobia, 453-468 
cephalalgia in, 458 
changes in nervous system, 

462 
death-rate of, 467 
deglutition in, 457 
etiology, 455 
fear of, 460 



Hydrophobia, incubation pe- 
riod, 455, 456 
inoculation in, protective, 

465 
medulla, changes in, 463 
melancholia, 456 
nerve-centres as affected in, 

462 
paralytic, 459 
paroxysm, 460 
post-mortem, appearances, 

. 455 
saliva, increased secretion 

of, 458 
sexual excitement in, 459 
spasm circulatoire, 458 
statistics of Pasteur Insti- 
tute, 468 
swallowing in, difficulty of, 

457 
temperature in, 459 
treatment, 464 

intensive method, 466 
prophylactic, 464 
protective, by digested 
cords, 468 
virus, modification of, 464 
virulence of, increased, 

465 
Hydrops articuli, 543 
Hygroma, 590, 591 
Hyperaemia, active, 79 

blood-flow in, increased, 

80 
caused by reflex action, 84 
changes in, 80 
changes due to vaso-mo- 

tor system, 81 
collateral innervation, 83 
paralysis of vasoconstric- 
tors, 82 
perivascular ganglia, 82 
and inflammation, combina- 
tion, of, 98 
catheterization of distended 

bladder, 87 
following tapping for ascites, 

87 
use of Esmarch bandage, 

. 8 7 . 
of irritation, 85 

of paralysis, 85 

passive, 88 
Hyperaemia, frog's tongue, 
study of, in, 89 

unilateral, cause of, 85 
Hyperesthesia in pyaemia, 370 
Hyperplasia of bone, 612 

increased length of, 615 
Hyperpyrexia, 311 
Hypertrophy of breast, 740 
Hysterectomy, 677 

ICHORRH^EMIA, 357 

Icterus in septicaemia, 347 



Immobility in wound treat- 
ment, 811 
Immunity, 39, 152 

phagocyte, theory of, 40, 

107 
to tetanus, 451 
Incisions, medical, 165 
in case of felon, 170 
multiple, in diffuse inflam- 
mation, 166 
Indican in urine, 794 
Infarctions in bone-tuberculo- 
sis, 518 
Infection, 73 

bacterial, in gangrene, 266, 

267 
entrance-gates of, sudoripa- 
rous gland-ducts the, 
172 
genito-urinary, in septicae- 
mia, 343 
of glanders, method of, 

486 
intravascular, in pyaemia, 

364 

of tuberculosis, 51 1 

mixed, 47 

in osteomyelitis, 195 

in pyaemia, route of, 36 1 

septic, 39, 338 

through uninjured skin, 42, 
138 

toxic, bacteria in, 39 

in tuberculosis, 61 

through the skin, 510 
Inflammation, action, chemi- 
cal, a cause, 1 21 

age as a factor, 125 

asthenic, 126 

attraction theory of, 96, 1 18 

bacteria in, can it exist 
without, 122 

cause of, 121 

blood-vessels in, 92 

catarrhal, 128 

causes of, 121 

cell-infiltration dependent 
on an amount of irrita- 
tion, 108 

changes in vessel-wall, 95 

circulation in, 92 

color of the part, II I 

cornea, experiments on, 102 

croupous, 128 

a damage, 120 

defined, 120 

diffuse, multiple incisions in, 
166 

dilatation of blood-vessels, 

95 
diphtheritic, 1 28 
distention of capillaries in, 

92 
disturbance of, a process of 

nutrition, 119 



INDEX. 



865 



Inflammation, escape of fluids 
from blood-vessels, 108 
excitor, 96 

experiment with thermome- 
ter in, Hunter, 1 15 
exudation in, 94 

causing swelling, III 
favoring bacterial develop- 
ment, 149 
fibrin formation in, 108 
formation of stomata in ves- 
sel-walls, 113 
function of leucocytes in, 

106 
heat as a symptom of, 1 15 
in the treatment of, 133 
hemorrhagic, 129 
hepatization, 112 
idiopathic, 125 
impairment of function in, 

117 
infective, 135 

due to bacteria, 135, 139 
thrombus formation, 147 
toxic, products of bac- 
teria in, 138 
interstitial, 127 
joint, in pyaemia, 377 
leeching affected area in, 

132 
leucocytes, 100 
nerves in, action of, 123 
non-infective, 126 
oedema, collateral, 112 
phlegmonous, 162 
resolution a termination of 

129 
rubor, symptom of, no 
serous, 127 

of skin in erysipelas, 388 
sloughs in, 162 

treatment, 164 
sthenic, 126 

swelling a symptom, in 
symptoms, cardinal, no 
temperature, local increase 

of, 116 
termination of, 129 
tissue-cells in, proliferation 

of, 104 
tissues in, action of, 1 01 

elasticity, 96 
treatment of, 130 

cold in, 133 
tumor, a symptom of, ill 
wandering cells in, 101 
white blood-corpuscles, in- 
crease of, 99 
Inflammations, erysipelas, ma- 
lignant, 393 
. of joints, metastatic, 543 
toxic, 121 
Infusion of salt solution, 299 
Injuries, railway, shock from, 
293 
55 



Injury a cause of osteomyeli- 
tis, 197 
Inoculation experiments, ery- 
sipelas, 382 
in hydrophobia, 465 
of pyogenic cocci in man, 

experimental, 139 
of the skin, tubercular, 563 
protective, bacterial, 39 
Inoculations in hydrophobia, 
preparation of cords for 
protective, 465 
Instruments, sterilization of, 

806 
Intercellular capillary devel- 
opment, 229 
Intestine, sarcoma of, 729 
Intestines, cancer of, 689 
Intoxication, septic, 337 

in hospital gangrene, 428 
Iodoform, 354, 803 

in surgical asepsis, 790 
causing fever, 323 
in joint-tuberculosis, 548 
use of, in surgery, 790 
Iron, chloride of, in erysipe- 
las, 404 
Itrol, 803 
Ivory exostosis, 769 

Jaws, hysterical contraction 
of, simulating tetanus, 

445 
Joint, cartilage in, 767 

elbow-, tuberculosis, 539 

hip-, disease of, 535 
Joint - affection in pyaemia, 

371 
Joint-inflammation in pyaemia, 

377 
Joint-mice, 767 
Joint-tuberculosis, 529 

ankylosis following, 534 
true, 534 

arthrectomy, 554 

arthropathia 529 

arthrotomy, 553 

atrophy of bone, 534 

caries sicca, 531 

changes in soft parts, 532 

disturbances, febrile, 541 

diagnosis, 542 

in elbow-joint, 539 

extension in, 547 

fixation, knee-joint, 536 
muscular, 549 

growth of osteophytes, 533 

heat in, 541 

hip-disease, 535 

mortality, 545 

osteopathic, 529 

pain in, 540 

primary synovial form, 531 

prognosis, 544 

resection, 552, 556 



Joint-tuberculosis, results of, 
542 
shoulder-joint, 538 
spasms, muscular, 533 
synovitis, obliterating, 529 
treatment, constitutional, 

545 
iodoform in, 548 
plaster-of-Paris in, 546 

tumor albus, 537 
Joints, adventitious, in rick- 
ets, 606 

as affected by hospital gan- 
grene, 428 

bacteriological examination 
of, 789 

changes in, degeneration of 
the spinal cord a cause, 
624 

in exanthemata, metastatic 
inflammations of, 543 

most usually attacked in 
bone-tuberculosis, 518 

in pyaemia, 377 

tuberculosis of, 529-557 

Karyokinesis, 104, 218 

daughter-stars, 219 

metakinesis, 219 

mother-stars, 219 
Karyomitosis, 219 
Keloid in negroes, 755 
Keratosis, 652 

complexion in, 652 

linguae, 679 
Kidney, in adeno-carcinoma, 

'697 
adenoma of, 741 
angiosarcoma of, 719 
cancer of, 696 
myosarcoma of, 776 
routes of infection by bac- 
teria, 829 
sarcoma of, 718 
surgical, 332 
Kidneys, abscesses of, meta- 
static, 736 
as eliminators of bacteria, 

144 
in pyaemia, 376 
tuberculosis of, 581 
Knee, resection of, 556 

water on the, 544 
Knee-joint, tuberculosis of, 

536 
Kresol, 802 

Labia, cancer of, 657 
Lactation, suppressed shock, 

294 
Laparotomy in tubercular per- 
itonitis, 572 
Larynx, cancer of, 686 
concussion of, 290 
shock from 290 



866 



INDEX. 



Larynx, papilloma of, 753 

sarcoma of, 726 
Leeching affected area in in- 
flammation, 132 
Leiomyoma of stomach, 775 
Leontiasis ossium, 612 
Leprosy, bacillus of, 64 
Leucocytes, appropriation of 
foreign bodies, 103 
bacteria destroyed by, 106 
in cornea, 102 
in fever, suppurative, 329 
forms of, 104 
function of, in inflammation, 

106 
increase of, 786 
inflammation, 100 
mononuclear, 104 
polynucleated, 104 
in septicaemia, 347 
Leucocytosis, 100, 786 
Leucoma an early stage of 
cancer of the tongue, 
678 
Leukaemia, inflammatory, in 
osteomyelitis, 198 
pseudo-, 730 
Ligature, arterial, cicatrix af- 
ter, 253 
of arteries, 251-255 

double, 254 
in gangrene, line of de- 
marcation, 260 
role of thrombus after, 254 
of an artery, organization 
of thrombus after, 252 
Ligatures, sterilization of, 806 
Lime-salts of bone absorbed 
in osteomalacia, 597 
in rickets, deficient, 604 
Lip, cancer of, 655, 661 
metastasis in, 656 
smoking a cause, 655 
carbuncle of, 179 

thrombosis of facial vein 
in, 180 
Lipoma arborescens, 592, 623 
diffuse, 761 
fibro-, 761 
Lipomata, multiple, 762 
Liquor puris, 159 
Lock-jaw, 438 
Lumpy-jaw, 469 
Lung, abscess of, experimen- 
tal, 145 
contagion of tuberculosis 
through the, 509 
Lungs, condition of, in actino- 
mycosis, 474 
conditions in osteomyelitis, 

inflammatory, 204 
starting-points in septicae - 
mia, 342 
Lupus, 558 

development of, 560 



Lupus, hypertrophicus, 560 

maculosus, 559 

of mucous membrane, 565 

ulcerating form of, 559 

of vulva, 574 
Lymphangioma, 781 

cavernous, 781 

cystic, 782 
Lymphangitis, 331 
Lymphatic system in cancer, 

645 
Lymphatics, cancer extension 
through, 645 

in septicaemia, 347 

tuberculosis of, 585 

microscopic appearances, 
586 
Lymphoma, 731 

blood in, 733 

malignant, 730 

protozoa in, 734 
Lymphosarcoma, 730 
Lysol, 803 
Lyssa falsa seu nevrosa, 450 

Macrophagocytes, 107 
Mai perforans, 185 
Malignant tissue, microscop- 
ical examination of, 

795 
Mamma (see Breast). 
abscesses of, 165 
tuberculosis of, 583 
description, 584 
diagnosis, 585 
microscopic appearances, 
584 
Marrow, bone, pathological 
changes in, 616 
red, after spleen extirpation, 
616 
Mastitis, chronic, 739 
Meatus urinarius, disinfection 

of, 830 
Mechanical sterilization of 

skin, 802 
Medulla, regeneration of, in 

osteomyelitis, 201 
Melancholia in hydrophobia, 

456 
Melanosarcoma, 707, 710 
Meningitis from carbuncle, 
179 
following facial erysipelas, 
400 
Metabolism a source of heat, 

304 
Metakinesis in karyokinesis, 

219 
Metastases in cancer of breast, 
667 
of hand, 656 
of lip, 656 
of rectum, 692 
of tongue, 680 



Metastases in cancer of 
uterus, 675 

Micrococcus pyogenes tenuis, 
46 
tetragenus, 48 

Micro-organisms after entering 
the body, 143 
in hospital gangrene, 415 

Microphagocyte, 107 

Middle-ear suppuration, curet- 
ting the sinuses in, 379 

Migration of white corpuscles, 

93 

Milk, tuberculosis in, 509 

Mitosis, process, 219 
in suppuration, 155 

Mortality of head-tetanus, 442 
in hospital gangrene, 430 
in joint-tuberculosis, 545 
of snake-bite in India, 495 
of tetanus, 447 

Mortification, 256 

Mother-marks, 777 

Mother-stars, karyokinesis, 
218 

Mouth, bacteriology of, 812 
pathogenic bacteria of, 814 
preparation of, for operation, 

813 
Mucous membrane in glanders, 
488 
lupus of, 565 
tuberculosis of, 565 
Mucous membranes, erysipelas 

of, 397 
Mummification, 260 
Muscle-fibers, budding of, 237 
Muscle repair, 235, 236 

sarcoblasts in, 235, 236 
rupture in tetanus, 439 
Muscles as heat-producers, 

305 

tuberculosis of, 593 
Mycosis, 338 

toxic, 339 
Myelin sheath in nerve-repair, 

239, 240 
Myoma, 774 

fibro-, 775 

of ovary, 775 

of prostate, 776 

of uterus, 775 
Myosarcoma of kidney, 776 

of testis, 776 
Myxoglioma, 764 
Myxolipoma, 761 
Myxoma, 758 

hyaline, 759 
Myxosarcoma, 707, 759 

Nasal passages, sarcoma of, 

727 
Neck, adenitis of, tuberculous, 

586 
hydrocele of, 751 



INDEX. 



867 



Nock, shock from blows in 

the, 290 
Necrosis, 256 

bone, spontaneous fracture 

from, 200 
coagulation-, streptococci, 
148 
suppuration, 146 
in osteomyelitis, 199 

result of suppuration, 199 
total, 199 
phosphorus, 617 

carious teeth a cause of, 

617 
match-making, cause of, 

617 
symptoms, 618 
treatment, 619 
a sequel of osteomyelitis, 
207. (SzzCoagulalion.) 
Necrotic tissue, treatment of, 

809 
Negroes, keloid in, 755 
Nephro-phthisis, 581 
Nerve-action in fever, 313 

in urethral fever, 332 
Nerve-cells in repair, 241 
Nerve-centres as affected in 
hydrophobia, 462 
in shock, 284 
Nerve-changes in tetanus, 444 
Nerve-degeneration after sec- 
tion, 236 
Nerve-exhaustion in shock, 

28 3. 
Nerve-grafting, 243 

Nerve-injury a cause of teta- 
nus, 435 
causing shock, 286 
Nerve-irritation in shock, 281, 

283 
Nerve-operations, plastic, 243 
Nerve - paralysis, facial, in 

head-tetanus, 442 
Nerve-repair, time of regener- 
ative changes, 239 
myelin sheath in, 239, 240 
vicarious sensibility, 238 
Nerve-section, neuromata 

after, 241 
prognosis, 241 
symptoms, clinical, 241 
Nerve-suture, 242 
Nerve-tissue of brain, repair, 
242 
from pre-existing tissue, 
238 
Nerves, action of, in inflam- 
mation, 123 
constrictor, hot water as 

stimulant of the, 88 
heat-production through the, 

305 
trophic, herpes due to, 123 
vaso-constrictor, 82 



Nerves, vaso-dilator, 82 
Neurasthenia following shock, 

293 
Neuroglioma, 764 
Neuroma, 771 

of amputation-stumps, 773 

amyelinic, 771 

malignant, 772 

multiple, 772 

plexiform, 772 
Neuromata after nerve section, 

241 
Neuro-paralysis, 277 
Nipple, disease of, Paget's, 

671 
Noli-me-tangere, 654 
Noma, 270 

bacteria in, 270 
Nose, bacteriology of, 820 

sterilization of, 821 
Nucleus, 219 

disappearance after death, 

257 
Nutrition, process of, inflam- 
mation a disturbance 
of, 119 

Odontoma, 770 

Odor of breath in pyaemia, 

369 

Odors, foul, cause of septicae- 
mia, 343 
OZdema, collateral, 88 
inflammation in, 112 
of glottis in erysipelas, 398 
malignant, bacillus of, 67 
clinical examples, 163 
pseudo-, bacillus of, 69 
CEsophagectomy, 686 
GEsophagus, cancer of, 684, 
685 
stricture of, 685 
Omentum, tuberculosis of, 570 
Operation, Porro's, in ostitis 

deformans. 602 
Operations for cancer, 682, 

693 
I Ossification of bone-callus, 247 
Osteoblasts, bone, 246 
l Osteoclasts, 598 
J Osteoid chondroma, 765, 768 
sarcoma, 716 
Osteoma, 769 
spongiosum, 770 
' Osteomalacia, 597 

chemical changes in bone 

in. 599 
lime-salts of bone absorbed 

in . 597. 
medullary tissue of bones 

in, 598 
puerperal state influencing, 

600 
Osteomyelitis, diagnosis, 206 
etiology, 194 



Osteomyelitis, prognosis, 208 

treatment, 209 
Osteomyelitis, 193 

abscess- formation, 198 

amputation in, 211 

anatomical seat, 196 
situation of, 196 

bacteria in, 194 

blood-clot in after-treatment 
of, 215 

bone-chips in, 216 

in after-treatment of, 216 

bone fistula after, 214 

carcinoma in the granula- 
tions, 208 

cartilage, epiphyseal, in, 
199, 201 

causes of, predisposing, 197 

cavity after removal of ne- 
crosed bone, 201 

compact bone not affected, 
197 

dislocation resulting from, 
208 

eburnation, 208 

endocarditis in, 204 

epiphyseal line the seat of, 
196 
variety, 203 

experimental, 194 

fat in pus of, 204 

flat bones, 203 

followed by acute suppura- 
tive arthritis, 205 

formation of new bone, 200 

grave type, 206 

infection, entrance of, 195 

inflammatory conditions in, 
204 
leucaemia in, 198 

injury a cause of, 197 

involvement of the joint, 199 

multiplex, 202 

necrosis in, 199 

the result of suppuration 

in, 199 
a sequel of, 207 
total, 199 

nutrient artery in, 197 

operation for, time of, 211 

operations in, 210 

pus in, 198 

pyogenic cocci in, 194 

regeneration of the medulla, 
201 

resection in, 212 

separation of sequestrum, 
213 

septicaemia and pyaemia in, 
202 

sequelae, 207 

sequestra of bone in, 199 

staphylococci in, 194 

staphylococcus pyogenes 
aureus, 194, 195 



868 



INDEX. 



Osteomyelitis, a starting-point 
for septicaemia, 342 
symptoms, 193, 203 
trephining in, 211 
typhoid bacillus in, 196 
a cause of, 196 
Osteophytes, growth of, in 

joint-tuberculosis, 533 
Osteoporosis, 609 
bones affected, 610 
lacunar absorption in, 610 
symptoms, 61 1 
tuberculosis, 570 
Osteosarcoma, 712 
Ostitis deformans, 613 
bones affected, 614 
changes in bone, chemi- 
cal, 599 
in medullary tissue, 598 
deformities in, 601 
influence of puerperal 

state, 600 
operation in, Porro's, 602 
prognosis, 601 
symptoms, 600 
treatment, 602 
tropho - neurosis, reflex, 

600 
tubercular, 516 
Ovaries, tuberculosis of, 576 
Ovary, cysts of, 748 
dermoid, 749 
myoma of, 775 
Oxalic acid, 803 
Ozcena, tuberculous, 566 

Pacchionian bodies, 752 
Paget's disease, psorosperms 

in, 672 
Pain in cancer of breast, 666 
in joint-tuberculosis, 540 
rheumatic-like, in shoulder- 
joint tuberculosis, 538 
Palate, soft, sarcoma of, 728 
Papilloma, 751 
of larynx, 753 
villous, of bladder, 752 
Paralysis, facial nerve, in 
head-tetanus, 442 
of perivascular ganglia, 87 
hyperaemia of, 86 
neuro-, 277 

reflex vaso-motor, in shock, 
279 
Parovariuum cysts, 749 
Paroxysm, hydrophobia, 460 
Pasteur, fermentation theory 
of, 23 
treatment of rabies, 464 
Pasteur Institute, statistics, 

468, 469 
" Peccant humor," 1 13 
Penis, cancer of, 657, 661 
Peptone in pus, 159 
in pyaemic urine, 370 



Peptones, protective treatment 
of rabies with cords 
treated with, 468 
Periostitis, 628 
acute, 629 
albuminosa, 630 
non-suppurative, chronic, 

630 
treatment, 631 
tubercular, 569 
Peritoneum, first mentioned in 

poetry, 498 
Peritonitis, bacteriology of, 

834 
fibrinopurulent, 836 
hemorrhagic, 836 
mycotica, 836 
purulent, 837 
seropuiulent, 836 
tubercular, 569, 570 

Fallopian tubes a source 

of, 569 
laparotomy in, 572 
Permanganate of potassium, 

803 
Petri dish, 36 

Phagocyte theory of immunity, 
40 
of Metschnikoff, 40 
Phagocytes, giant-cells as, 107 

macro-, 107 
Phagocytosis, 41 

an explanation of immunity, 

107 
erysipelas, 107 
Pharynx, bacteriology of, 812 

sarcoma of, 728 
Phlogosin, 141 
Phosphorus in rickets, 609 
Pigeon breast, 607 
Placenta, passage of bacillus 

through the, 75 
Plasma canals in capillar}' de- 
velopment, 230 
cells, 220 
Plaster of Paris in treatment 
of joint-tuberculosis, 
546 
Plate culture, 36 
Plethora, 79 

Pleura, bacteriological exam- 
ination of, 789 
Pleurosthotonos, 441 
Pneumonia caused experi- 
mentally by infection 
of aureus, 145 
in pyaemia, 375 
Polyp, naso-pharyngeal, 727, 

757 
Port-wine marks, 777 
Post-mortem appearances in 
actinomycosis, 471 
in anthrax, 481 
in hospital gangrene, 429 
of hydrophobia, 462 



Post-mortem appearances in 
pyaemia, 375 
in rabies, 455 
in septicaemia, 349 
in tetanus, 443 
Postural drainage, 840 
Potatoes as nutrient media, 33 
Pott's disease, 513, 523 

tuberculosis, 524 
Poultice, antiseptic, 165 
Poultices, action of, 133 
Pregnancy a cause of cancer 

of uterus, 673 
Prostate, myoma of, 776 
Prostration without reaction, 

277 
Proteid, bacterial, 152 
defensive, 153 
protective, 153 
Proteus Hauser, 826 
Protoplasm, bacterial, 18 
Protozoa in cancer, 640 
cancer-cells as, 699 
in lymphoma, 734 
Proud' flesh, 187 
Psammoma, 783 
Pseudarthrosis, 250 
Pseudo-leukaemia, 730 

-tuberculosis, 595 
Psoas abscesses, 525 
Psorosperms, 641 

in Paget's disease, 672 
Ptomaines a cause of septicae- 
mia, 342 
Pus, action on necrosed bone, 
solvent, 200 
in blood, 363 

in pyaemia, 363 
blue, 160 

burrowing of, in palmar 
abscesses, course of, 
171 
calomel, 142 
laudable, 160 
in osteomyelitis, 198 

fat in, 204 
peptone in, 159 
red, 160 
sterile, 140 
tubercular, 160 
without bacteria, 140 
Pustule, 172 

malignant, 479 
Pyaemia, 356 
diagnosis, 378 
prognosis, 378 
symptoms, 366 
treatment, 378 
Pyaemia, abscesses in, meta- 
static, 362, 376 
miliary, 363 
bacteria of, 359 
blood in, 371 
blood-plaques in, 361 
bones in, 377 



INDEX. 



869 



Pyaemia, brain in, 376 
breath in, odor of, 369 
chills in, 306 
chronic, 374 
curetting vein of sinus in, 

379 
endocarditis, 360 

in ulcerating, 365, 372 
experimental, 358, 359 
heart in, 376 
history of, 356 
hyperesthesia, 370 
infection, intravascular, 364 

route of, 361 
inflammation of connective 

tissue in, 377 
influenced by age and sex, 
366 

by seasons, 365 
joint-affection in, 371 
joint-inflammation in, 377 
kidneys in, 376 
in osteomyelitis, 202 
pneumonia in, 375 
post-mortem appearances, 

375 
puerperal, 373 
pus in the blood in, 363 
in the thoracic duct in, 

3 6 4 
spontaneous, 364 
temperature in, 367 
thrombosis in, 361 
thrombo-phlebitis in, 361 
urine in, 370 
wounds predisposing to 

puerperal septicaemia, 

343 
Pyocyaneus, 47 
Pyogenes aureus, 801 
Pyoktanin in cancer, 700 
Pyuria, 792 

Rabies, 453 
dumb, 453, 455 
furious, 453. (See Hydro- 
phobia.) 
Ray-fungus, 469 
Rectum, adeno-carcinoma of, 
691 
cancer of, 690 

Kraske's operation, 693 
sterilization of, 831 
stricture of, from cancer, 

692 
tuberculosis of, 568 
Renal calculi, jr-rays in, 798 
Repair, arterial, compensatory 
endarteritis, 255 
of arteries, 250 
bone, 245, 249 

hyaline cartilage in, 249 
of brain nerve-tissue, 242 
first intention, 223 
vascular loops in, 233 



Repair in granulation tissue, 
vascular loops in, 228 
muscle, 235, 236 

sarcoblasts in, 235, 236 
nerve-cells in, 241 
nerve, myelin sheath in, 
239, 240 
time of regenerative 

changes, 239 
vicarious sensibility, 238 
the scar, 224 
second intention, 225 
tendon, 232 

blood-clot in, 233 
slumbering cells in, 234 
third intention, 232 
of tissue-cells, process, 104 
vascular, 229 
Resection in joint-tuberculosis, 
552, 556 
of knee, 556 
in osteomyelitis, 212 
Respiratory centre, action in 
hydrophobic paroxysm, 

4 6 . 1 
organs in elimination of bac- 
teria, 145 
Ribs, caries of the, 525 

tuberculosis of, 526 
Rice-bodies, 590 
Rickets, 603 

appearances of, microscopic, 

605 
bones most affected in, 608 
cartilage-cells in, 605 
change in disposition, 608 
changes in, pathological, 

604 
craniotabes, 606 
debility favoring, 603 
deformities following, 606 
distribution, 604 
fcetal, 604 
fontanelles in, 606 
joints in, adventitious, 606 
lime-salts in, deficient, 604 
phosphorus in, 609 
prognosis, 608 
thickening of ends of bones, 

605 
treatment, 609 
Risus sardonicus, 439 
Rontgen rays in surgical diag- 
nosis, 796 
Rosary, rachitic, 607 
Rubber gloves, 805 
Rubor, symptom of inflamma- 
tion, no 
Rupture, muscle, in tetanus, 
439 

Sacroiliac synchondrosis, 

tuberculosis of, 528 
Salicylic acid, 803 
Salol, 834 



Salt-solution as a genito-urin- 
ary germicide, 833 

infusion of, 299 
Sapraemia, 337 

symptoms, 343 
Sarcoblasts in muscle-repair, 

235. 236 
Sarcoma, 702 

action of erysipelas cocci 
on, 735 

alveolar, 705 

of bones of cranium, 717 

changes in, retrograde, 708 

chondro-, 716 

Cohnheim's theory regard- 
ing, 7°3 

etiology, 703 

giant-cells, 706 

metastatic, 708 

organisms in, 704 

osteo-, 712 

osteoid, 716 

periosteal, 544, 715 

pigment, multiple, 71 1 

pigmented, 707 

prognosis, 724 

round-cell, large, 705 

spindle-cell, central, 713 

treated by streptococcus of 
erysipelas, 734 

of the air-passages, 725 

of bladder, 719 

of bone, 712 

central round-cell, 714 

spindle-cell of, 713 
spontaneous fracture in, 

714 
of brain, 729 
of breast, 723 

malignancy, 724 
of intestine, 729 
of kidney, 718 
of larynx, 726 
of nasal passages, 727 
of pharynx, 728 
of soft palate, 728 
of stomach, 729 
of testis, 721 
of tonsil, 725 
of uterus, 720 
osteoid, 716 
pigment, multiple, 71 1 
Sardonic grin, 439 
Scarlet fever (see Fever). 

surgical, liability of chil- 
dren to, 324 
Scar-tetanus, 435 
Schluck-pneumonia, 123 
Scirrhus cutis, 651 
Scrofula, bacteria in, 594 
bone disease in relation to 
tuberculosis, 515 
Scrofuloderma, 561 
Scrotum, cancer of, 658 

tar and paraffin in, 659 



870 



INDEX. 



Sea-voyage in tuberculosis, 

580 
Section, nerve, degeneration 
after, 238 
neuromata after, 241 
prognosis, 241 
Sepsis and asepsis of the 

Greeks, 785 
Septicaemia, diagnosis, 353 
symptoms, 343 
treatment, 353 
alcohol in, 354 
Septicaemia, a bacterial dis- 
ease, 336 
bacteria in, 337 
cause of foul odor, a, 343 
ptomaines a, 342 
trauma a predisposing, 

341 

diarrhoea in, 347 

disinfectants in, 354 

entrance of poison, 341 

eruption in, scarlet, 347 

euphoria in, 348 

genito-urinary infection, 343 

icterus in, 347 

leucocytes in, 347 

lungs starting-points of, 342 

lymphatics in, 347 

in osteomyelitis, 202 

osteomyelitis a starting- 
point for, 342 

post-mortem appearances, 

349 
puerperal, 343 
spontaneous, 352 
temperature in, 346 
Sequestra of bone in osteomy- 
elitis, 199 
Sequestrum, separation of, in 
osteomyelitis, 213 
in tarsus, 522 
Sero-therapy of syphilis, 850 
of tetanus, 846 
of tuberculosis, 849 
Shock, 277 
diagnosis, 295 
prognosis, 297 
symptoms, 296 
treatment, 297 
enemata in, 299 
Shock, age influencing, 293 
from blows in the neck, 290 
from burns, 290 
causes of, 288 
cells of cord in, 285 
from concussion of larynx, 

290 
hemorrhage causing, 286 
hospitals, table for patients 
in, 298 
auto-infusion, 299 
insidious, 287 

irritation in pneumogastric, 
281 



Shock, local, 288 

mental emotion a cause of, 
292 
condition in, 294 
nature of, 279 
nerve-centres in, 284 
nerve-exhaustion in, 283 
nerve-injury causing, 286 
nerve-irritation in, degrees 
of, 283 
mechanical, 283 
pneumogastric, 281 
neurasthenia following, 293 
over-stimulation of nerves, 

283 
pain in, 291 
clinical picture, 278 
from railway injuries, 293 
reflex vaso-motor paralysis, 

279 
semilunar ganglion, 289 
stimulants in, 299 
suppressed lactation, 294 
temperature in, 294 
torpid form, 286 
varieties, 286 
vaso-motor theory of, 280 
vomiting in, 294 
Shoulder-joint, tuberculosis of, 
538 
caries sicca in, 538 
Silver nitrate in genitourinary 

germicide, 8^3 
Sinuses, curetting the, in mid- 
dle-ear suppuration, 379 
Skiagraphy in surgical diag- 
nosis, 796 
Skin, actinomycosis of, 475 
cancer of, 652, 660 
deep-seated, 649 
superficial, 650 
carcinoma of, 648 
condition of, pathological, 

in erysipelas, 398 
fibroma of, multiple, 754 
infection of tuberculosis 

through the, 510 
inflammation of, in erysipe- 
las, 388 
inoculation, tubercular, 561 
pigmentation, 90 
sterilization of, 801 
surgical bacteriology of, 
800 
Skin-grafting, 189 
Skin-tuberculosis, 558 

treatment, 563 
Slough, 128 

Sloughs in phlegmonous in- 
flammation, 162 
Slumbering-cell theory, Gra- 

witz, 105, 220 
Smoking, a cause of lip can- 
cer, 655 
Snake-bite, 495, 503 



Snake-bite, antitoxic serum in, 

503 

changes following, patho- 
logical, 499 

mechanism of, 497 

mortality of, in India, 495 

stimulants in, 501 

symptoms, 498 

treatment, 500 
strychnia in, 502 

venom of, action, 497 
Snakes, death from, in India, 

495 
venom, secretion of, 496 
Spasm, muscular, in joint- 
tuberculosis, 533 
Spasmotoxin, 55 
Spasms in tetanus, 438, 437 
Spermatocele, 743 
Spina ventosa, 521 
Spinal-cord degeneration a 
cause of changes in 
joints, 624 
Spinal puncture, 794 
Spirilla, 21 

Sponges, sterilization of, 806 
Spore-formation, bacteria, 20 

-staining, Moller, 29 
Spores, bacillus, anthrax, 72 
anthrax, theory of dissemi- 
nation by earth-worms, 
478 
Sporulation, 21 
Sputa, staining for the bacilli 

of tuberculosis, 57 
Staining, bacteria, methods, 26 
removal of haemoglobin 

and fat in, 29 
spores, 29 
sputa for the bacilli of tu- 
berculosis, 57 
Staphylococci, 21 

in osteomyelitis, 194 
Staphylococcus, action of, pep- 
tonizing, 146 
albus or skin, 801 
cereus albus, 26, 45 

flavus, 26, 45 
epidermidis albus, 790 
pyogenes albus, 45 
aureus, 43 

in osteomyelitis, 194, 

195 
citreus, 45 
in cystitis, 828 
viridis flavescens, 45 
Sterilization, 31 
dry heat, 32 
of ear, 819 
fractional, 31 
of mouth, 813 
of nose, 821 
of rectum, 831 
of skin, 801 
steam, 32 



INDEX. 



8 7 I 



Sterilization of urethra; 830 

of vagina, 831 

of vulva, 831 
Sterilizer, Arnold, 32 
Sternum, tuberculosis of, 527 
Stimulants in shock, 299 

in snake-bite, 501 
Stomach, cancer of, 688 

leiomyoma of, 775 

sarcoma of, 729 
Streptobacrlus anthracoides, 

S27 
Streptococci, 21 

action of, in suppuration, 146 
on the tissues, 146 

in coagulation-necrosis, 148 

in erysipelas, 382, 383, 384, 

399 
point of entrance in, 382, 

386 
seat of, 384 
in treatment of sarcoma, 

734 
erysipelatis, 53 
pyogenes, 46 
Streptococcus pyogenes in 

cystitis, 826 
Stricture of oesophagus, 685 

of rectum from cancer, 692 
Structure picture, 25 
Struma, 743 

Strychnia-poisoning simulating 
tetanus, 445 
in snake-bite, 502 
Styrone, 803 
Sugar of the blood, 787 
Sulphates in urine, 794 
Sulpho-naphtol, 803 
Suppuration, 129, 135, 155— 
161 
action of streptococcus, 146 
bacteria in, frequency, 139 
number of, necessary to 

cause, 137 
peptonizing action of, a 
cause of, 155 
coagulation - necrosis, 146, 

148 
croton oil producing, 140 
defined, 141 
etiology, 151 

conclusion, 159 
favored by season of the 

year, 150 
fluctuation, 158 
foreign bodies cannot pro- 
duce, 143 
locality as favoring, 151 
middle-ear, curetting the 

sinuses in, 379 
mitosis in, 155 
necrosis the result of, in 

osteomyelitis, 199 
symptoms in constitutional, 
158 



Surgeons' hands, disinfection 

of, 805 
Surgical bacteriology of skin, 
800 
diagnosis, bacteriological ex- 
amination in, 788 
blood-examination in, 786 
examination of feces, 795 
Rontgen rays in, 796 
scientific aids to, 785 
spinal puncture in, 794 
urinary conditions in, 790 
kidney, 826 
Suture, tension from, causing 
aseptic fever, 323 
nerve, 242 
Sutures, sterilization of, 806 
Sweat-glands, adenoma of, 

650, 740 
Sweating in defervescence, 31 1 
Swelling in inflamed organs, 
causes, 112 
a symptom of inflammation, 
ill 
Syncope, 296 
Synovitis following erysipelas, 

392 
obliterative, in joint-tuber- 
culosis, 529 
Syphilis bacillus, 65, 66 
Lustgarten, 66 
sero-therapy of, 850 
Syringomyelia, 764 

Tabes mesenterica, 570 

Tar and paraffin in cancer of 

scrotum, 659 
Teeth, carious, a cause of 
p hos phor us - necrosis, 
617 
Temperature, bacteria in, 22 
body, inequalities in, 302 

regulation, 302 
constant, by chemical 
changes resulting from 
nerve-action, 307 
local increase of, in inflam- 
mation, 1 16 
Temperature in aseptic fever, 
320 
in suppurative fever, 328 
in traumatic fever, 317 
in hospital gangrene, 426 
in hydrophobia, 459 
in pyaemia, 367 
in saprsemia, 345 
in septicaemia, 346 
in shock, 294 
in tetanus, 440 
Tendon cicntrix, 234 
healing of, 232 
repair, 232 

blood-clot in, 233 
slumbering cells in, 234 
union of, after section, 235 



Tendon-sheaths infected from 
a felon, 169 
tuberculosis of, 589-593 
Teratoma, 749 
Testicle, cancer of, 698 
tuberculosis of, 576 
castration in, 580 
relation of trauma to, 577 
symptoms, 578 
Testis, adenoma of, 742 
myosarcoma, 776 
sarcoma of, 721 
Tetani, bacillus of, 53, 435 
Tetanin, 55, 436 
Tetanoloxin, 55 
Tetanus, 434-452 
diagnosis, 444 
prognosis, 447 
sero-therapy in, 846 
symptoms, 438 
treatment, 448, 804 
antiseptic, 449 
blood-serum in, 451 
Calabar bean in, 448 
chloral in, 448 
chloroform in, 449 
vapor bath in, 450 
Tetanus, acute, 437 
age in relation to, 437 
antitoxine, 451, 804 
bacilli in garden soil, 436 
bacillus, when found, 436 
caused by eating infected 

flesh, 436 
cephalic, 442 
chronic, 441 
epidemics of, 437 
frequency of, in the tropics, 

434 
head, 441, 442 
facial-nerve paralysis in, 

442 
hydrophobicus, 441 
hysterical contraction of 

jaws simulating, 445 
immunity to, 451 
mortality of, 447 
muscle rupture in, 439 
muscles in, masseter, 438 
nerve-changes in, 444 
nerve-injury a cause of, 

435. . 
nerve-origin, 434 
post-mortem changes in, 

443 

scar-, 435 

spasm in, tonic, 438 

spasms in, 439 

strychnia-poisoning simulat- 
ing, 445 

temperature in, 440 

wounds in, character of, 

443. 
following punctured 
wounds, 436 



872 



INDEX. 



Tetany, 446 

Therapy, blood-serum in, 153 

Thiersch skin-grafting, 189 

solution, 831 
Throat, acute infectious in- 
flammation of, diagno- 
sis of, 816 
tuberculosis of, 565 
Thrombi, infective, 147 

coagulation-necrosis after, 
147, 148 
Thrombo-phlebitis, 147 

in pyaemia, 361 
Thrombosis, infective, appear- 
ance of tissue after, 148 
in pyaemia, 361, 375 
of facial vein in carbuncle 
of lips, 180 
Thrombus formation in infec- 
tive inflammation, 147 
organization of, after ligature 

of an artery, 252 
role of, after ligature of arte- 
ries, 254 
Thymus gland (see Gland). 
Thyroid, accessory, 745 

extract, treatment with, 

747 
Tissue, appearance of, after 
infective inflammation, 
148 
abscess, wall of, 157 
bone, destruction of, in hip- 
joint disease, 536 
cicatricial, contraction, 226 
connective, 220, 665 

inflammation of, in pyae- 
mia, 375, 376 
granulation, 157, 226 
epithelioid cells in, 229 
intercellular substance in, 

229 
spindle-cells in, 227 
vascular loops in, 228 
medullary, of bones in osteo- 
malacia, 598 
changes in, in ostitis de- 
formans, 598 
nerve, repair in brain, 242 
from pre-existing tissue, 
238 
new, capillary development 

in, 229 
repair in granulation, vascu- 
lar loops in, 228 
Tissue-cells, proliferation of, 
in inflammation, 104 
repair of, process, 104 
Tissue-metamorphosis, theory, 

103 
Tissues, action of streptococ- 
cus on the, 146 
bacterial development in, 
mechanical conditions 
favoring, 149 



Tissues, hardening of, patho- 
logical, 30, 807 
inflamed, fibrin formed in, 
108 
fluids in, 108 
in inflammation, action of, 
101 
elasticity of, 96 
Tongue, black, 397 

cancer of (see Cancer) . 
of the frog, changes caused 

by ligature, 94, 97 
tuberculosis of, 566 
warts a pre-cancerous stage 

in the, 679 
wooden-, 476 
Tonsil, sarcoma of, 725 
Tooth-filling, antiseptics of, 

815 
Torpor, traumatic, 277 
Toxalbumin, 152 
Trauma a cause of inflamma- 
tion, 121 
predisposing cause of septi- 
caemia, 341 
relation of, to tuberculosis 

of testicle, 577 
tumors from, 636 
Traumatism in cancer of 

breast, 663 
Treatment of wounds, 807 
Trephining in osteomyelitis, 

211 
Tropho-neurosis, reflex, in os- 
titis deformans, 600 
Tubercle, anatomical, 510, 
562 
submillary, bacilli in, 506 
Tuberculin T. R., 849 
Tuberculosis, 504-528 
abscesses, cold, 519 
absorption of small nodules, 

518 
bacilli in, 505 

staining sputa for the, 57 
bacillus of, 56 

Koch's demonstration of, 

505 
Ziehl's method of stain- 
ing for, 57 
cartilage in, ulceration of, 

531 
cheesy degeneration in, 

507 

connective-tissue, 589 
contagion through the lung, 

509 
contagiousness of, 504 
cutis vera, 560 
degeneration in tubercle, 

507 
direction of disease in gen- 

ito-urinary tract, 577 
entrance of virus, mode, 

508 



Tuberculosis, epithelioid cells 
in, 506 , 

exanthemata, a predisposing 

cause, 511 
experimental, 515 
fistula in ano, 567 
frequency of, 512 
giant-cells in, 59, 505 
gonorrhoea a factor in spread 

of. 575 
hectic fever, 519 
hereditary, 508 
hydrops articuli, 531 
infection in, 61 

genital tract aided by 
gonorrhoea, 575 

genito-urinary tract, 573 

intravascular, 51 1 

through the skin, 510 
inoculability of, 504 
in joints, 514, 529 
miliary, following opera- 
tions, 534 
in milk, 509 
often multiple, 512 
papillomatosa cutis, 563 
Pott's disease, 524 
pseudo-, 595 
psoas abscess, 525 
rice-bodies, 590 
sea-voyage in, 580 
secondary, 510 
sero-therapy of, 849 
spread of, from bone to joint, 

530 

transmission of, in the rite 

of circumcision, 510 
urethritis, 574 
verrucosa cutis, 562 
vertebral column common- 
est seat of, 523 
vesicula seminalis, 578 
zooglceica, 595 
Tuberculosis of bladder in 
women, 579 
of bone, 513 

absorption of diseased 
portion, 522 

cheesy sequestra, 517 

diagnosis, 521 

infarctions in, 518 

joints most usually at- 
tacked, 535 

lesion, seat of, 521 

secondary changes, 517 
of elbow -joint, 539 
of face, 528 
of Fallopian tubes, 573 
genito-urinary, 573-583 
of mesenteric glands, 570 
joint-, 529-557 

ankylosis following, 534 

bone-atrophy in, 534 

extension of, 547 

pain in, 540 



INDEX. 



873 



Tuberculosis, joint-, resection 

in, 552 

treatment of, iodoform in, 
548 
plaster of Paris in, 546 
of kidneys, 581 
of knee-joint, 536 
of lymphatic glands, prog- 
nosis, 588 
of lymphatics, 585-589 
of mamma, 583, 584 
of membrane, 519 

of abscess, 520 
of mucous membrane, 565 
of muscles, 593 
of omentum, 750 
of ovaries, 576 
of rectum, 568 
of ribs, 526 
of sacro-iliac synchondrosis, 

528 
of shoulder-joint, caries sic- 
ca in, 538 
of skin, 558 

treatment, 563 
of sternum, 527 
of tendon-sheaths, 589 

symptoms, 591 

treatment, 593 
of testicle, 576, 580 

relation of trauma to, 

577 
symptoms, 578 

of throat, 565 

of tongue, 566 

of urethra, 581 

of uterus, 573 

of vagina, 574 

of vulva, 574 
Tumor albus, 537 

inflammation a symptom of, 
ill 
Tumors, 633 

benign, 737 

bone, myeloid, 713 

classification, 637 

embryonic theory of origin, 

635 
heredity, 636 
heterologous, 634 
homologous, 634 
from trauma, 636 
Turpentine, Chian, in cancer, 

701 
Typhoid, bone, 193 
Tyrotoxicon, 342 

Ulcer, 182 

blood-pigment in, 184 

callous, 187 

caused by infectious disease, 

182 
characteristics of, anatomi- 
cal, 182 
defined, 182 



Ulcer, erethistic, 186 
fungous, 187 
inflammatory, 184 
mal-perforant, 185 
phagedenic, 188 
from pressure, 185 
rodent, 649-655 
malignancy of, 654 
treatment, 661 
treatment of, 188 
varicose, 184 
Ulceration of cartilage in tu- 
berculosis, 531 
endocarditis in, 363, 365, 
372 
Ulcerations, tuberculous, 563 
Ulcers, phagedenic, 188 
strapping, 189 
torpid, 187. (See Ulcer.) 
Urea, excretion of, 312 

in urine, 794 
Urethra, disinfection of, 830 
male, bacteria of, 824, 825 
tuberculosis of, 581 
Urinary casts, 792 

conditions in surgical diag- 
nosis, 790 
Urine, amount of, 790 

bacteriological examination 

of, 790 
color of, 791 
extravasation of, cause of 

gangrene, 270 
in pyaemia, 370 
Urobacillus liquefaciens septi- 

cus, 826 
Urotropine, 834 
Uterus, cancer of (see Cancer). 
diagnosis, 676 
hemorrhage, an early 
symptom of, 676 
heredity in, 673 
hydrometra in, 675 
myoma of, 775 
pregnancy a cause of, 673 
sarcoma of, 720 
tuberculosis of, 573 

Vaccination against bacillus 
anthracis, 74 
erysipelas following, 385 
Vagina, sterilization of, 831 

tuberculosis of, 574 
Vapor-bath in tetanus, 450 
Vascular loops in granulation 

tissue, 228 
Vaso-constrictor nerves, 82 
Vaso-motor centre, 81 

disturbance cause of sym- 
metrical gangrene, 274 
theory of shock, 280 
Venom secretion of snakes, 

496 
Vertebral column, commonest 
seat of tuberculosis, 523 



Vesicles in erysipelas, 389 
Vesicula seminalis, tuberculo- 
sis of, 578 
Vessel-wall in inflammation, 

changes in, 95 
Vessel-walls, molecular 
changes in, causes of 
inflammatory phenom- 
ena, 118 
stomata in, formation of, in 
inflammation, 113 
Virus, erysipelas, 382 

hydrophobia, increased vir- 
ulence, 465 
modification of, 464 
tuberculosis, mode of en- 
trance, 508 
Vomiting in shock, 294 
Vulva, bacteria of, 825 
lupus of, 575 
sterilization of, 831 
tuberculosis of, 574 

Wall of abscess tissue, 157 

Wart, venereal, 752 

Warts a pre-cancerous stage in 

the tongue, 679 
Water in the knee, 544 
Wens, orbital, 751 
White blood-count, 786 
Whitlow, melanotic, 710 
Women, tuberculosis of blad- 
der in, 579 
Wooden-tongue, 476 
Wool-sorters' disease, 76, 479 
Wound, closing of, 81 1 

erysipelas, condition of, 390 

treatment, 407 
flaps, coaptation of, 222 
Wound-healing, 221 

-infection, avoidance of, 801 
-treatment, immobility in, 
811 
Wounds, dissecting-room, 350 
dressings for, 81 1 
dryness of, 810 
non-infection of, in same 
person in hospital gan- 
grene, 419 
punctured, followed by teta- 
nus, 436 
treatment of, 807 

X-RAY DERMATITIS, 8oO 

X-rays in diagnosing fracture, 

797 
renal calculi, 798 
in locating foreign bodies, 

797 
Xeroderma pigmentosum, 660 
Xerosis bacillus, 818 
Xylol balsam, 29 

Ziehl's solution, 27 
Zymotic disease, 17 



CATALOGUE 

OF THE 



MEDICAL PUBLICATIONS 



OF 



W* B. SAUNDERS, 

No. 925 WALNUT STREET, PHILADELPHIA, 



Arranged Alphabetically and Classified under Subjects* 



THE books advertised in this Catalogue as being sold by subscription are usually to be 
obtained from travelling solicitors, but they will be sent direct from the office of pub- 
lication (charges of shipment prepaid) upon receipt of the prices given. All the other 
books advertised are commonly for sale by booksellers in all parts of the United States; but 
books will be sent to any address, carnage prepaid, on receipt of the published price. 

Money may be sent at the risk of the publisher in either of the following ways : A post- 
office money order, an express money order, a bank check, and in a registered letter. Money 
sent in any other way is at the risk of the sender. 

See pages 30, 31, for a List of Contents classified according to subjects. 



LATEST PUBLICATIONS. 



International Text-Book of Surgery* See page 32. 

American Text-Book of Surgery — Third (Revised) Edition. See page 5. 

American Text-Book of Dis. of Eye, Ear, Nose, and Throat. Page 3. 

American Text-Book of Genito-Urinary and Skin Diseases. Page 4. 

Heisler's Embryology. See page 32. 

Nancrede's Principles of Surgery. See page 32. 

Jackson's Diseases of the Eye. See page 32. 

Kyle on the Nose and Throat. See page 15. 

Pryor's Pelvic Inflammations. See pages 19 and 32. 

Abbott's Hygiene of Transmissible Diseases. See page 32. 

Anders' Practice of Medicine — Third (Revised) Edition. See page 6. 

Vierordt's Medical Diagnosis — Fourth (Revised) Edition. See page 29. 

Church and Peterson's Nervous and Mental Diseases. See page 8. 

Da Costa's Surgery — Revised and Enlarged Edition. See page 10. 

Saunders' Medical Hand-Atlases. See page 2. 

Griffith on the Baby — Revised Edition. See page 12. 

Butler's Materia Medica and Therapeutics — Third (Revised) Ed. Page 8. 

De Schweinitz's Diseases of the Eye — Tf hird (Revised) Ed. See page 10. 

Vecki's Sexual Impotence. See page 28. 

Stoney's Materia Medica for Nurses. See page 28. 

McFarland's Pathogenic Bacteria — Revised Edition. See page 17. 

American Pocket Medical Dictionary — Second (Revised) Ed. Page 10. 

Stengel's Text-Book of Pathology. Second Edition. See page 26. 

Hirst's Text-Book of Obstetrics. See page 13. 



SAUNDERS' MEDICAL HAND-ATLASES. 



The series of books included under this title consists o'f authorized translations into 
English of the world-famous Lehmann Medicinische Handatlanten, which for sci- 
entific accuracy, pictorial beauty, compactness, and cheapness surpass any similar 
volumes ever published. Each volume contains from 50 to 100 colored plates, executed 
by the most skilful German lithographers, besides numerous illustrations in the text. There 
is a full and appropriate description of each plate, and each book contains a condensed 
but adequate outline of the subject to which it is devoted. 

One of the most valuable features of these atlases is that they offer a ready and satis- 
factory substitute for clinical observation. To those unable to attend important clinics 
these books will be absolutely indispensable. 

In planning this series of books arrangements were made with representative publishers 
in the chief medical centers of the world for the publication of translations of the atlases 
into nine different languages, the lithographic plates for all these editions being made in Ger- 
many, where work of this kind has been brought to the greatest perfection. The expense of 
making the plates being shared by the various publishers, the cost to each one was materially 
reduced. Thus by reason of their universal translation and reproduction, the publish- 
ers have been enabled to secure for these atlases the best artistic and professional 
talent, to produce them in the most elegant style, and yet to offer them at a price 
heretofore unapproached in cheapness. The success of the undertaking is demon- 
strated by the fact that the volumes have already appeared in nine different languages 
— German, English, French, Italian, Russian, Spanish, Danish, Swedish, and Hungarian. 

In view of the striking success of these works, Mr. Saunders has contracted with the 
publisher of the original German edition for one hundred thousand copies of the atlases. 
In consideration of this enormous undertaking, the publisher has been enabled to prepare 
and furnish special additional colored plates, making the series even handsomer and more 
complete than was originally intended. 

As an indication of the practical value of the atlases and of the favor with which they 
have been received, it should be noted that the Medical Department of the U. S. Army 
has adopted the "Atlas of Operative Surgery" as its standard, and has ordered the book in 
large quantities for distribution to the various regiments and army posts. 

The same careful and competent editorial supervision has been secured in the 
English edition as in the originals, the translations being edited by the leading American 
specialists in the different subjects. 

NOW READY. 

Atlas of Internal Medicine and Clinical Diagnosis. By Dr. Chr. Jakob, of Erlangen. Edited 
by Augustus A. Eshner, M.D., Professor of Clinical Medicine in the Philadelphia Polyclinic; At- 
tending Physician to the Philadelphia Hospital. 68 colored plates, and 64 illustrations in the text. 
Cloth, $3.00 net. 

Atlas of Legal Medicine. By Dr. E. R. von Hofmann, of Vienna. Edited by Frederick Peter- 
son, M.D., Clinical Professor of Mental Diseases, Woman's Medical College, New York; Chiei 
of Clinic, Nervous Dept., College of Physicians and Surgeons, New York. With 120 colored fig- 
ures on 56. plates, and 193 beautiful half-tone illustrations. Cloth, $3.50 net. 

Atlas of Diseases of the Larynx. By Dr. L. Grunwald, of Munich. Edited bv Charles P. 
Grayson, M.D., Lecturer on Laryngology and Rhinologv in the University of Pennsylvania; 
Physician-in-Charge, Throat and Nose Department, Hospital of the University of Pennsylvania. 
With 107 colored figures on 44 plates, and 25 text-illustrations. Cloth, $2.50 net. 

Atlas of Operative Surgery. By Dr. O. Zuckkrkandl, of Vienna. Edited by J. Chalmers 
DaCosta, M.D., Clinical Professor of Surgery, Jeriei son Medical College, Philadelphia ; Surgeon 
to the Philadelphia Hospital. With 24 colored plates, and 217 text illustrations. Cloth, $3.00 net. 

Atlas of Syphilis and tne Venereal Diseases. By Prof. Dr. Franz Mracek, of Vienna. Edited 
by L. Bolton Bangs, M. D., Professor of Genito-Urinary Surgery, University and Bellevue Hospi- 
tal Medical College, New York. With 71 colored plates, 16 black-and-white illustrations, and 122 
pages of text. Cloth, $3.50 net. 

Atlas of External Diseases of the Eye. By Dr. O. Haab, of Zurich. Edited by G. E. 
de Schweinitz, M. D., Professor of Ophthalmology, Jefferson Medical College, Philadelphia. 
With 76 colored illustrations on 40 plates, and 228 pages of text. Cloth, $3.00 net. 

Atlas of Skin Diseases. By Prof. Dr. Franz Mracek, of Vienna. Edited by Henry W. Stelwagon, 
M. D., Clinical Professor of Dermatology, Jefferson Medical College, Philadelphia. 63 colored plates, 
39 beautiful half-tone illustrations, and 200 pages of text. Cloth, $3.50 net. 

IN PREPARATION. 

Atlas of Pathological Histology. Atlas of Operative Gynecology. 

Atlas of Orthopedic Surgery. Atlas of Psychiatry. 

Atlas of General Surgery. Atlas of Diseases of the Ear. 




THE AMERICAN TEXT-BOOK SERIES. 

AN AMERICAN TEXT=BOOK OF APPLIED THERAPEUTICS. 

By 43 Distinguished Practitioners and Teachers. Edited by James C. 
Wilson, M.D., Professor of the Practice of Medicine and of Clinical 
Medicine in the Jefferson Medical College, Philadelphia. One hand- 
some imperial octavo volume of 1326 pages. Illustrated. Cloth, 
$7.00 net; Sheep or Half Morocco, $8.00 net. Sold by Subscription. 

" As a work either for study or reference it will be of great value to the practitioner, as 
it is virtually an exposition of such clinical therapeutics as experience has taught to be oi 
the most value. Taking it all in all, no recent publication on therapeutics can be compared 
with this one in practical value to the working physician." — Chicago Clinical Review. 

" The whole field of medicine has been well covered. The work is thoroughly prac- 
tical, and while it is intended for practitioners and students, it is a better book for the general 
practitioner than for the student. The young practitioner especially will find it extremely 
suggestive and helpful." — The Indian Lancet. 

AN AMERICAN TEXT=BOOK OF THE DISEASES OF CHILDREN. 
Second Edition, Revised. 

By 65 Eminent Contributors. Edited by Louis Starr, M. D., Con- 
sulting Pediatrist to the Maternity Hospital, etc. ; assisted by Thomp- 
son S. Westcott, M. D., Attending Physician to the Dispensary 
for Diseases of Children, Hospital of the University of Pennsyl- 
vania. In one handsome imperial octavo volume of 1244 pages, 
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"This is far and away the best text-book on children's diseases ever published in the 
English language, and is certainly the one which is best adapted to American readers. 
We congratulate the editor upon the result of his work, and heartily commend it to the 
attention of every student and practitioner." — American Journal of the Medical Sciences. 

AN AMERICAN TEXT=BOOK OF DISEASES OF THE EYE, EAR, 
NOSE, AND THROAT. 

By 58 Prominent Specialists. Edited by G. E. de Schweinitz, M.D., 
Professor of Ophthalmology in the Jefferson Medical College, Phila- 
delphia ; and B. Alexander Randall, M.D., Professor of Diseases 
of the Ear in the University of Pennsylvania. Imperial octavo, 1251 
pages; 766 illustrations, 59 of them in colors. Cloth, $7.00 net; Sheep 
or Half Morocco, $8.00 net. Sold by Subscriptio?i. 

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4 Medical Publications of W. B. Saunders. 

AN AMERICAN TEXT=BOOK OF GENITOURINARY AND SKIN 
DISEASES. 

By 47 Eminent Specialists and Teachers. Edited by L. Bolton 
Bangs, M. D., Professor of Genito- Urinary Surgery, University and 
Bellevue Hospital Medical College, New York ; and W. A. Hard- 
away, M. D., Professor of Diseases of the Skin, Missouri Medical 
College. Imperial octavo volume of 1229 pages, with 300 engravings 
and 20 full-page colored plates. Cloth, $7.00 net; Sheep or Half 
Morocco, $8.00 net. Sold by Subscription. 

" This volume is one of the best yet issued of the publisher's series of ' American Text- 
Books.' The list of contributors represents an extraordinary array of talent and extended 
experience. The book will easily take the place in comprehensiveness and value of the 
half dozen or more costly works on these subjects which have heretofore been necessary to 
a well-equipped library." — New York Polyclinic. 

AN AMERICAN TEXT=BOOK OF GYNECOLOGY, MEDICAL AND 
SURGICAL. Second Edition, Revised. 

By 10 of the Leading Gynecologists of America. Edited by J. M. 
Baldy, M. D., Professor of Gynecology in the Philadelphia Polyclinic, 
etc. Handsome imperial octavo volume of 718 pages, with 341 illus- 
trations in the text, and 38 colored and half-tone plates. Cloth, $6.00 
net ; Sheep or Half Morocco, $7.00 net. Sold by Subscription. 

" It is practical from beginning to end. Its descriptions of conditions, its recommen- 
dations for treatment, and above all the necessary technique of different operations, are 
clearly and admirably presented. . . . It is well up to the most advanced views of the 
day, and embodies all the essential points of advanced American gynecology. It is destined 
to make and hold a place in gynecological literature which will be peculiarly its own."— 
Medical Record, New York. 

AN AMERICAN TEXT=BOOK OF LEGAL MEDICINE AND TOXI- 
COLOGY. 

Edited by Frederick Peterson, M. D. , Clinical Professor of Mental 
Diseases in the Woman's Medical College, New York; Chief of Clinic, 
Nervous Department, College of Physicians and Surgeons, New York ; 
and Walter S. Haines, M.D., Professor of Chemistry, Pharmacy, 
and Toxicology in Rush Medical College, Chicago. In Preparation. 

AN AMERICAN TEXT=BOOK OF OBSTETRICS. 

By 15 Eminent American Obstetricians. Edited by Richard C. Nor- 
ris, M.D.; Art Editor, Robert L. Dickinson, M.D. One handsome 
imperial octavo volume of 1014 pages, with nearly 900 beautiful colored 
and half-tone illustrations. Cloth, $7.00 net; Sheep or Half Morocco, 
$8.00 net. Sold by Subscription. 

" Permit me to say that your American Text-Book of Obstetrics is the most magnificent 
medical work that I have ever seen. I congratulate you and thank you for this superb work, 
which alone is sufficient to place you first in the ranks of medical publishers. " — ALEXANDER 
J. C. Skene, Professor of Gynecology in the Long Island College Hospital, Brooklyn, N. Y. 

" This is the most sumptuously illustrated work on midwifery that has yet appeared. In 
the number, the excellence, and the beauty of production of the illustrations it far surpasses 
every other book upon the subject. This feature alone makes it a work which no medical 
library should omit to purchase." — British Medical Journal. 

"As an authority, as a book of reference, as a ' working book ' for the student or prac- 
titioner, we commend it because we believe there is no better." — American Journal of the 
Medical Sciences. 



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Medical Publications of W. B. Saunders. 5 

AN AMERICAN TEXT=BOOK OF PATHOLOGY. 

Edited by John Guiteras, M.D., Professor of General Pathology and 
of Morbid Anatomy in the University of Pennsylvania ; and David 
Riesman, M.D. , Demonstrator of Pathological Histology in the 
University of Pennsylvania. In Prepciratio?i. 

AN AMERICAN TEXT-BOOK OF PHYSIOLOGY. 

By i o of the Leading Physiologists of America. Edited by William 
H. Howell, Ph.D., M.D., Professor of Physiology in the Johns Hop- 
kins University, Baltimore, Md. One handsome imperial octavo 
volume of 1052 pages. Illustrated. Cloth, $6.00 net j Sheep or Half 
Morocco, $7.00 net. Sold by Subscription. 

" We can commend it most heartily, not only to all students of physiology, but to every 
physician and pathologist, as a valuable and comprehensive work of reference, written by 
men who are of eminent authority in their own special subjects." — London Lancet. 

" To the practitioner of medicine and to the advanced student this volume constitutes, 
we believe, the best exposition of the present status of the science of physiology in the 
English language." — American Journal of the Medical Sciences. 

AN AMERICAN TEXT=BOOK OF SURGERY. Third Edition. 

By 11 Eminent Professors of Surgery. Edited by William W. Keen, 
M.D., LL.D., and J. William White, M.D., Ph.D. Handsome im- 
perial octavo volume of 1230 pages, with 496 wood-cuts in the text, 
and 37 colored and half-tone plates. Thoroughly revised and enlarged, 
with a section devoted to " The Use of the Rontgen Rays in Surgery." 
Cloth, S7.00 net; Sheep or Half Morocco, $8.00 net. 

«' Personally, I should not mind it being called THE Text-Book (instead of A Text- 
Book) , for I know of no single volume which contains so readable and complete an account 
of the science and art of Surgery as this does." — Edmund Owen, F.R.C.S., Member of 
the Board of Examiners of the Royal College of Surgeons, England. 

" If this text-book is a fair reflex of the present position of American surgery, we must 
admit it is of a very high order of merit, and that English surgeons will have to look very 
carefully to their laurels if they are to preserve a position in the van of surgical practice." — 
London Lancet. 

AN AMERICAN TEXT=BOOK OF THE THEORY AND PRACTICE 
OF MEDICINE. 

By 12 Distinguished American Practitioners. Edited by William 
Pepper, M.D., LL.D., Professor of the Theory and Practice of Medi- 
cine and of Clinical Medicine in the University of Pennsylvania. Two 
handsome imperial octavo volumes of about 1000 pages each. Illus- 
trated. Prices per volume : Cloth, $5.00 net ; Sheep or Half Morocco, 
$6.00 net. Sold by Subscription. 

" I am quite sure it will commend itself both to practitioners and students of medicine, 
and become one of our most popular text-books." — Alfred Loomis, M.D., LL.D., Pro- 
fessor of Pathology and Practice of Medicine, University of the City of New York. 

" We reviewed the first volume of this work, and said : * It is undoubtedly one of the 
best text-books on the practice of medicine which we possess.' A consideration of the 
second and last volume leads us to modify that verdict and to say that the completed work 
is in our opinion the best of its kind it has ever been our fortune to see. " — New York Medical 
Journal. 

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6 Medical Publications of W. B. Saunders. 

AN AMERICAN YEAR-BOOK OF MEDICINE AND SURGERY. 

A Yearly Digest of Scientific Progress and Authoritative Opinion in all 
branches of Medicine and Surgery, drawn from journals, monographs, 
and text-books of the leading American and Foreign authors and 
investigators. Collected and arranged, with critical editorial com- 
ments, by eminent American specialists and teachers, under the general 
editorial charge of George M. Gould, M.D. One handsome imperial 
octavo volume of about 1200 pages. Uniform in style, size, and 
general make-up with the "American Text-Book" Series. Cloth, 
$6.50 net; Half Morocco, $7.50 net. Sold by Subscription. 

" It is difficult to know which to admire most — the research and industry of the distin- 
guished band of experts whom Dr. Gould has enlisted in the service of the Year-Book, or the 
wealth and abundance of the contributions to every department of science that have been 
deemed worthy of analysis. . . . It is much more than a mere compilation of abstracts, 
for, as each section is entrusted to experienced and able contributors, the reader has the 
advantage of certain critical commentaries and expositions . . . proceeding from writers 
fully qualified to perform these tasks. . . . It is emphatically a book which should find 
a place in every medical library, and is in several respects more useful than the famous 
'Jahrbucher' of Germany." — London Lancet. 

THE AMERICAN POCKET MEDICAL DICTIONARY. 

[See Dor land'' 's Pocket Dictionary, page 10.] 

ANDERS' PRACTICE OF MEDICINE. Third Revised Edition. 
A Text-Book of the Practice of Medicine. By James M. Anders, 
M.D., Ph.D., LL.D., Professor of the Practice of Medicine and of 
Clinical Medicine, Medico-Chirurgical College, Philadelphia. In one 
handsome octavo volume of 1292 pages, fully illustrated. Cloth, 
$5.50 net; Sheep or Half Morocco, $6.50 net. 

*' It is an excellent book, — concise, comprehensive, thorough, and up to date. It is a. 
credit to you ; but, more than that, it is a credit to the profession of Philadelphia — to us." 
James C. Wilson, Professor of the Practice of Medicine and Clinical Medicine, Jefferson 
Medical College, Philadelphia. 

ASHTON'S OBSTETRICS. Fourth Edition, Revised. 

Essentials of Obstetrics. By W. Easterly Ashton, M.D., Pro- 
fessor of Gynecology in the Medico-Chirurgical College, Philadelphia. 
Crown octavo, 252 pages; 75 illustrations. Cloth, $1. 00 ; interleaved 
for notes, $1.25. 

[See Saunders' Question- Compends, page 21.] 

" Embodies the whole subject in a nut-shell. We cordially recommend it to our read- 
ers." — Chicago Medical Times. 

BALL'S BACTERIOLOGY. Third Edition, Revised. 

Essentials of Bacteriology ; a Concise and Systematic Introduction 
to the Study of Micro-organisms. By M. V. Ball, M.D., Bacteriol- 
ogist to St. Agnes' Hospital, Philadelphia, etc. Crown octavo, 218 
pages; 82 illustrations, some in colors, and 5 plates. Cloth, $1.00; 
interleaved for notes, $1.25. 

[See Saunders' Question- Compends, page 21.] 

" The student or practitioner can readily obtain a knowledge of the subject from a perusal 
of this book. The illustrations are clear and satisfactory." — Medical Record, New York. 



Medical Publications of W. B. Saunders. 1 

BASTIN'S BOTANY. 

Laboratory Exercises in Botany. By Edson S. Bastin, M.A., 
late Professor of Materia Medica and Botany, Philadelphia College of 
Pharmacy. Octavo volume of 536 pages, with 87 plates. Cloth, $2.50. 

"It is unquestionably the best text-book on the subject that has yet appeared. The 
work is eminently a practical one. We regard the issuance of this book as an important 
event in the history of pharmaceutical teaching in this country, and predict for it an unquali- 
fied success." — Alumni Report to the Philadelphia College of Pharmacy. 

"There is no work like it in the pharmaceutical or botanical literature of this country, 
and we predict for it a wide circulation." — American Journal of Pharmacy. 

BECK'S SURGICAL ASEPSIS. 

A Manual of Surgical Asepsis. By Carl Beck, M.D«, Surgeon to 
St. Mark's Hospital and the New York German Poliklinik, etc. 306 
pages; 65 text-illustrations, and 12 full-page plates. Cloth, $1.25 net. 

" An excellent exposition of the ' very latest' in the treatment of wounds as practised 
by leading German and American surgeons." — Birmingham (Eng.) Medical Review. 

"This little volume can be recommended to any who are desirous of learning the details 
of asepsis in surgery, for it will serve as a trustworthy guide." — London Lancet. 

BOISLINIERE'S OBSTETRIC ACCIDENTS, EMERGENCIES, AND 
OPERATIONS. 
Obstetric Accidents, Emergencies, and Operations. By L. Ch. 

Boisliniere, M.D., late Emeritus Professor of Obstetrics, St. Louis 
Medical College. 381 pages, handsomely illustrated. Cloth, $2.00 net. 

" It is clearly and concisely written, and is evidently the work of a teacher and practi- 
tioner of large experience." — British Medical Journal. 

" A manual so useful to the student or the general practitioner has not been brought to 
our notice in a long time. The field embraced in the title is covered in a terse, interesting 
way." — Yale Medical Journal. 

BROCKWAY'S MEDICAL PHYSICS. Second Edition, Revised. 
Essentials of Medical Physics. By Fred J. Brockway, M.D., 
Assistant Demonstrator of Anatomy in the College of Physicians and 
Surgeons, New York. Crown octavo, 330 pages; 155 fine illustrations. 
Cloth, $1.00 net ; interleaved for notes, $1.25 net. 

[See Saunders* Question- Comp ends, page 21.] 

" The student who is well versed in these pages will certainly prove qualified to com- 
prehend with ease and pleasure the great majority of questions involving physical principles 
likely to be met with in his medical studies." — American Practitioner and News. 

"We know of no manual that affords the medical student a better or more concise 
exposition of physics, and the book may be commended as a most satisfactory presentation 
of those essentials that are requisite in a course in medicine." — New York Medical Journal. 

" It contains all that one need know on the subject, is well written, and is copiously 
illustrated." — Medical Record, New York. 

BURR ON NERVOUS DISEASES. 

A Manual of Nervous Diseases. By Charles W. Burr, M.D., 
Clinical Professor of Nervous Diseases, Medico-Chirurgical College, 
Philadelphia ; Pathologist to the Orthopedic Hospital and Infirmary 
for Nervous Diseases; Visiting Physician to St. Joseph's Hospital, etc. 
Jn Preparation. 



8 Medical Publications of W. B. Saunders. 

BUTLER'S MATERIA MEDICA, THERAPEUTICS, AND PHAR- 
MACOLOGY. Third Edition, Revised. 
A Text=Book of Materia Medica, Therapeutics, and Pharma- 
cology. By George F. Butler, Ph.G., M.D., Professor of Materia 
Medica and of Clinical Medicine in the College of Physicians and 
Surgeons, Chicago; Professor of Materia Medica and Therapeutics, 
Northwestern University, Woman's Medical School, etc. Octavo, 874 
pages, illustrated. Cloth, $4.00 net; Sheep, $5.00 net. 

" Taken as a whole, the book may fairly be considered as one of the most satisfactory 
of any single-volume works on materia medica in the market," — Journal of the American 
Medical Association. 

CERNA ON THE NEWER REMEDIES. Second Edition, Revised. 
Notes on the Newer Remedies, their Therapeutic Applications 
and Modes of Administration. By David Cerna, M.D., Ph.D., 
formerly Demonstrator of and Lecturer on Experimental Therapeutics 
in the University of Pennsylvania ; Demonstrator of Physiology in the 
Medical Department of the University of Texas. Rewritten and 
greatly enlarged. Post-octavo, 253 pages. Cloth, $1.25. 

" The appearance of this new edition of Dr. Cerna's very valuable work shows that it 
is properly appreciated. The book ought to be in the possession of every practising physi- 
cian." — New York Medical Journal. 

CHAPIN ON INSANITY. 

A Compendium of Insanity. By John B. Chapin, M.D., LL.D., 

Physician-in-Chief, Pennsylvania Hospital for the Insane ; late Physi- 
cian-Superintendent of the Willard State Hospital, New York ; Hon- 
orary Member of the Medico-Psychological Society of Great Britain, 
of the Society of Mental Medicine of Belgium. i2mo, 234 pages, 
illustrated. Cloth, $1.25 net. 

" The practical parts of Dr. Chapin's book are what constitute its distinctive merit. We 
desire especially to call attention to the fact that on the subject of therapeutics of insanity 
the work is exceedingly valuable. It is not a made book, but a genuine condensed thesis, 
which has all the value of ripe opinion and all the charm of a vigorous and natural style." — 
Philadelphia Medical Journal. 

CHAPMAN'S MEDICAL JURISPRUDENCE AND TOXICOLOGY. 
Second Edition, Revised. 
Medical Jurisprudence and Toxicology. By Henry C. Chapman, 
M.D., Professor of Institutes of Medicine and Medical Jurisprudence 
in the Jefferson Medical College of Philadelphia. 254 pages, with 55 
illustrations and 3 full-page plates in colors. Cloth, $1.50 net. 

"The best book of its class for the undergraduate that we know of." — New York 
Medical Times. 

CHURCH AND PETERSON'S NERVOUS AND MENTAL DISEASES. 
Nervous and Mental Diseases. By Archibald Church, M. D., 

Professor of Mental Diseases and Medical Jurisprudence in the North- 
western University Medical School, Chicago ; and Frederick Peter- 
son, M. D., Clinical Professor of Mental Diseases, Woman's Medical 
College, N. Y.; Chief of Clinic, Nervous Dept., College of Physi- 
cians and Surgeons, N. Y. Handsome octavo volume of 843 pages, 
profusely illustrated. Cloth, $5.00 net j Half Morocco, $6.00 net. 



Medical Publications of W. B. Saunders. 9 

CLARKSON'S HISTOLOGY. 

A Text=Book of Histology, Descriptive and Practical. By 
Arthur Clarkson, M.B., CM. Edin., formerly Demonstrator of 
Physiology in the Owen's College, Manchester; late Demonstrator of 
Physiology in Yorkshire College, Leeds. Large octavo, 554 pages; 
22 engravings in the text, and 174 beautifully colored original illustra- 
tions. Cloth, strongly bound, $4.00 net. 

" The work must be considered a valuable addition to the list of available text- books, 
and is to be highly recommended." — New York Medical Journal. 

" This is one of the best works for students we have ever noticed. We predict that the 
book will attain a well-deserved popularity among our students." — Chicago Medical Recorder. 

CLIMATOLOGY. 

Transactions of the Eighth Annual Meeting of the American 
Climatological Association, held in Washington, September 22-25, 
1 89 1. Forming a handsome octavo volume of 276 pages, uniform with 
remainder of series. (A limited quantity only.) Cloth, $1.50. 

COHEN AND ESHNER'S DIAGNOSIS. 

Essentials of Diagnosis. By Solomon Solis-Cohen, M.D., Pro- 
fessor of Clinical Medicine and Applied Therapeutics in the Philadel- 
phia Polyclinic ; and Augustus A. Eshner, M.D., Professor of Clinical 
Medicine in the Philadelphia Polyclinic. Post-octavo, 382 pages; 55 
illustrations. Cloth, $1.50 net. 

[See Saunders' Question- Compends, page 21.] 

" We can heartily commend the book to all those who contemplate purchasing a 'com- 
pend.' It is modern and complete, and will give more satisfaction than many other works 
which are perhaps too prolix as well as behind the times." — Medical Review, St. Louis. 

CORWIN'S PHYSICAL DIAGNOSIS. Third Edition, Revised. 

Essentials of Physical Diagnosis of the Thorax. By Arthur 
M. Corwjx, A.M., M.D., Demonstrator of Physical Diagnosis in Rush 
Medical College, Chicago ; Attending Physician to Central Free Dis- 
pensary, Department of Rhinology, Laryngology, and Diseases of the 
Chest, Chicago. 219 pages, illustrated. Cloth, flexible covers, $1.25 net. 

"It is excellent. The student who shall use it as his guide to the careful study of 
physical exploration upon normal and abnormal subjects can scarcely fail to acquire a good 
working knowledge of the subject." — Philadelphia Polyclinic. 

"A most excellent little work. It brightens the memory of the differential diagnostic 
signs, and it arranges orderly and in sequence the various objective phenomena to logical 
solution of a careful diagnosis. " — Journal of Nervous and Mental Diseases. 

CRAGIN'S GYNAECOLOGY. Fourth Edition, Revised. 

Essentials of Gynaecology. By Edwin B. Cragix, M. D., Lecturer, 
in Obstetrics, College of Physicians and Surgeons, New York. Crown 
octavo, 200 pages; 62 illustrations. Cloth, $1.00 ; interleaved for notes, 
$1.25- 

[See Saunders' Question- Compends, page 21.] 

"A handy volume, and a distinct improvement on students' compends in general. No 
author who was not himself a practical gynecologist could have consulted the student's needs 
so thoroughly as Dr. Cragin has done." — Medical Record, Nevtf York. 



10 Medical Publications of W. B. Saunders. 

CROOKSHANK'S BACTERIOLOGY. Fourth Edition, Revised. 

A Text=Book of Bacteriology. By Edgar M. Crookshank, M.B., 
Professor of Comparative Pathology and Bacteriology, King's College, 
London. Octavo volume of 700 pages, with 273 engravings and 22 
original colored plates. Cloth, $6.50 net; Half Morocco, $7.50 net. 

" To the student who wishes to obtain a good resume of what has been done in bacteri- 
ology, or who wishes an accurate account of the various methods of research, the book may 
be recommended with confidence that he will find there what he requires." — London Lancet. 

Da COSTA'S SURGERY. Second Ed., Revised and Greatly Enlarged. 
Modern Surgery, General and Operative. By John Chalmers 
DaCosta, M.D., Clinical Professor of Surgery, Jefferson Medical 
College, Philadelphia ; Surgeon to the Philadelphia Hospital, etc. 
Handsome octavo volume of 900 pages, profusely illustrated. Cloth, 
$4.00 net; Half Morocco, $5.00 net. 

"We know of no small work on surgery in the English language which so well fulfils 
the requirements of the modern student." — Medico-Chirurgical Journal, Bristol, England. 

DE SCHWEINITZ ON DISEASES OF THE EYE. Third Edition, 
Revised. 
Diseases of the Eye. A Handbook of Ophthalmic Practice. 

By G. E. de Schweinitz, M.D., Professor of Ophthalmology in the 
Jefferson Medical College, Philadelphia, etc. Handsome royal octavo 
volume of 696 pages, with 256 fine illustrations and 2 chromo-litho- 
graphic plates. Cloth, $4.00 net ; Sheep or Half Morocco, $5.00 net. 

" A clearly written, comprehensive manual. One which we can commend to students 
as a reliable text-book, written with an evident knowledge of the wants of those entering 
upon the study of this special branch of medical science." — British Medical Journal. 

" A work that will meet the requirements not only of the specialist, but of the general 
practitioner in a rare degree. I am satisfied that unusual success awaits it." — William 
Pepper, M.D., Professor of the Theory and Practice of Medicine and Clinical Medicine, 
University of Pennsylvania. 

DORLAND'S DICTIONARY. Second Edition, Revised. 

The American Pocket Medical Dictionary. Containing the Pro- 
nunciation and Definition of all the principal words and phrases, and a 
large number of useful tables. Edited by W. A. Newman Dorland, 
M. D., Assistant Demonstrator of Obstetrics, University of Pennsylvania; 
Fellow of the American Academy of Medicine. 518 pages ; handsomely 
bound in full leather, limp, with gilt edges and patent index. Price, 
$1.00 net; with thumb index, $1.25 net. 

DORLAND'S OBSTETRICS. 

A Manual of Obstetrics. By W. A. Newman Dorland, M.D., 
Assistant Demonstrator of Obstetrics, University of Pennsylvania; 
Instructor in Gynecology in the Philadelphia Polyclinic. 760 pages; 
163 illustrations in the text, and 6 full-page plates. Cloth, $2.50 net. 

" By far the best book on this subject that has ever come to our notice." — American 
Medical Review. 

" It has rarely been our duty to review a book which has given us more pleasure in its 
perusal and more satisfaction in its criticism. It is a veritable encyclopedia of knowledge, 
a gold mine of practical, concise thoughts." — American Medico-Surgical Bulletin. 



Medical Publications of W. B. Saunders, 11 

FROTHINGHAM'S GUIDE FOR THE BACTERIOLOGIST. 

Laboratory Guide for the Bacteriologist. By Langdon Froth- 
INGHAM, M.I). Y.. Assistant in Bacteriology and Veterinary Science, 
Sheffield Scientific School, Vale University. Illustrated. Cloth, 75 cts. 

"It is a convenient and useful little work, and will more than repay the outlay neces- 
sary for its purchase in the saving of time which would otherwise be consumed in looking 
up the various points of technique so clearly and concisely laid down in its pages." — Ameri- 
can Medico- Surgical Bulletin. 

GARRIGUES' DISEASES OF WOMEN. Second Edition, Revised. 
Diseases of Women. By Henry J. Garrigues, A.M., M.D., Pro- 
fessor of Gynecology in the New York School of Clinical Medicine ; 
Gynecologist to St. Mark's Hospital and to the German Dispensary, 
New York City, etc. Handsome octavo volume of 728 pages, illus- 
trated by 335 engravings and colored plates. Cloth, $4.00 net; 
Sheep or Half Morocco, $5.00 net. 

" One of the best text-books for students and practitioners which has been published in 
the English language ; it is condensed, clear, and comprehensive. The profound learning 
and great clinical experience of the distinguished author find expression in this book in a 
most attractive and instructive form. Young practitioners to whom experienced consultants 
may not be available will find in this book invaluable counsel and help." — Thad. A. 
Reamy, M.D., LL.D., Professor of Clinical Gynecology, Medical College of Ohio. 

GLEASON'S DISEASES OF THE EAR. Second Edition, Revised. 
Essentials of Diseases of the Ear. By E. B. Gleason, S.B., 
M.D., Clinical Professor of Otology, Medico-Chirurgical College, 
Philadelphia ; Surgeon-in-Charge of the Nose, Throat, and Ear Depart- 
ment of the Northern Dispensary, Philadelphia. 208 pages, with 
114 illustrations. Cloth, $1.00 ; interleaved for notes, $1.25. 
[See Saunders'' Question- Comp ends, page 21.] 

" It is just the book to put into the hands of a student, and cannot fail to give him a 
useful introduction to ear-affections ; while the style of question and answer which is adopted 
throughout the book is, we believe, the best method of impressing facts permanently on the 
mind. " — Liverpool Medico- Chirurgical Journal. 

GOULD AND PYLE'S CURIOSITIES OF MEDICINE. 

Anomalies and Curiosities of Medicine. By George M. Gould, 
M.D., and Walter L. Pyle, M.D. An encyclopedic collection of 
rare and extraordinary cases and of the most striking instances of 
abnormality in all branches of Medicine and Surgery, derived from an 
exhaustive research of medical literature from its origin to the present 
day, abstracted, classified, annotated, and indexed. Handsome im- 
perial octavo volume of 968 pages, with 295 engravings in the text, 
and 12 full-page plates. Cloth, $6.00 net; Half Morocco, $7.00 net. 
Sold by Subscription. 

" One of the most valuable contributions ever made to medical literature. It is, so far 
as we know, absolutely unique, and every page is as fascinating as a novel. Not alone for 
the medical profession has this volume value: it will serve as a book of reference for all who 
are interested in general scientific, sociologic, or medico-legal topics." — Brooklyn Medical 
Journal. 

"This is certainly a most remarkable and interesting volume. It stands alone among 
medical literature, an anomaly on anomalies, in that there is nothing like it elsewhere in 
medical literature. It is a book full of revelations from its first to its last page, and cannot 
but interest and sometimes almost horrify its readers." — American Medico- Surgical Bulletin. 



12 Medical Publications of W. B. Saunders. 

GRAFSTROM'S MECHANOTHERAPY. 

A Text=Book of Mechanotherapy (Massage and Medical Gym= 
nasties). By Axel V. Grafstrom, B. Sc, M. D., late Lieutenant in 
the Royal Swedish Army ; late House Physician City Hospital, Black- 
well's Island, New York. i2mo, 139 pages, illustrated. Cloth, $1.00 net. 

GRIFFITH ON THE BABY. Second Edition, Revised. 

The Care of the Baby. By J. P. Crozer Griffith, M.D., Clini- 
cal Professor of Diseases of Children, University of Pennsylvania ; 
Physician to the Children's Hospital, Philadelphia, etc. 121110, 404 
pages, with 67 illustrations in the text, and 5 plates. Cloth, $1.50. 

" The best book for the use of the young mother with which we are acquainted. . . . 
There are very few general practitioners who could not read the book through with advan- 
tage. ' ' — Archives of Pediatrics. 

"The whole book is characterized by rare good sense, and is evidently written by a 
master hand. It can be read with benefit not only by mothers but by medical students and 
by any practitioners who have not had large opportunities for observing children." — Avieri- 
can Journal of Obstetrics. 

GRIFFITH'S WEIGHT CHART. 

Infant's Weight Chart. Designed by J. P. Crozer Griffith, M.D., 
Clinical Professor of Diseases of Children in the University of Penn- 
sylvania, etc. 25 charts in each pad. Per pad, 50 cents net. 

A convenient blank for keeping a record of the child's weight during the first two years 
of life. Printed on each chart is a curve representing the average weight of a healthy infant, 
so that any deviation from the normal can readily be detected. 

GROSS, SAMUEL D., AUTOBIOGRAPHY OF. 

Autobiography of Samuel D. Gross, M.D., Emeritus Professor of 
Surgery in the Jefferson Medical College, Philadelphia, with Remi- 
niscences of His Times and Contemporaries. Edited by his Sons, 
Samuel W. Gross, M.D., LL.D., late Professor of Principles of Sur- 
gery and of Clinical Surgery in the Jefferson Medical College, and 
A. Haller Gross, A.M., of the Philadelphia Bar. Preceded by a 
Memoir of Dr. Gross, by the late Austin Flint, M.D., LL.D. In 
two handsome volumes, each containing over 400 pages, demy octavo, 
extra cloth, gilt tops, with fine Frontispiece engraved on steel. Price 
per volume, $2.50 net. 

" Dr. Gross was perhaps the most eminent exponent of medical science that America 
has yet produced. His Autobiography, related as it is with a fulness and completeness 
seldom to be found in such works, is an interesting and valuable book. He comments on 
many things, especially, of course, on medical men and medical practice, in a very interest- 
ing way." — The Spectator, London, England. 

HAMPTON'S NURSING. Second Edition, Revised and Enlarged. 
Nursing : Its Principles and Practice. By Isabel Adams Hamp- 
ton, Graduate of the New York Training School for Nurses attached 
to Bellevue Hospital ; late Superintendent of Nurses and Principal of 
the Training School for Nurses, Johns Hopkins Hospital, Baltimore, 
Md. 12 mo, 512 pages, illustrated. Cloth, $2.00 net. 

" Seldom have we perused a book upon the subject that has given us so much pleasure 
as the one before us. We would strongly urge upon the members of our own profession the 
need of a book like this, for it will enable each of us to become a training school in him- 
self." — Ontario Medical Journal. 



Medical Publications of W. B. Saunders. 13 

HARE'S PHYSIOLOGY. Fourth Edition, Revised. 

Essentials of Physiology. By H. A. Hare, M.D., Professor of 
Therapeutics and Materia Medica in the Jefferson Medical College of 
Philadelphia. Crown octavo, 239 pages. Cloth, $1.00 net; inter- 
leaved lor notes, $1.25 net. 

[See Saunders' Question- Compends, page 21.] 

" The best condensation of physiological knowledge we have yet seen." — Medical 
Record, New York. 

HART'S DIET IN SICKNESS AND IN HEALTH. 

Diet in Sickness and in Health. By Mrs. Ernest Hart, formerly 
Student of the Faculty of Medicine of Paris and of the London School 
of Medicine for Women ; with an Introduction by Sir Hendry 
Thompson, F.R.C.S., M.D., London. 220 pages. Cloth, $1.50. 

" We recommend it cordially to the attention of all practitioners ; both to them and to 
their patients it may be of the greatest service." — New York Medical Journal. 

HAYNES' ANATOMY. 

A Manual of Anatomy. By Irving S. Haynes, M.D., Adjunct 
Professor of Anatomy and Demonstrator of Anatomy, Medical Depart- 
ment of the New York University, etc. 680 pages, illustrated with 42 
diagrams in the text, and 134 full-page half-tone illustrations from 
original photographs of the author's dissections. Cloth, $2.50 net. 

" This book is the work of a practical instructor — one who knows by experience the 
requirements of the average student, and is able to meet these requirements in a very satis- 
factory way. The book is one that can be commended." — Medical Record, New York. 

HEISLER'S EMBRYOLOGY. 

A Text=Book of Embryology. By John C. Heisler, M.D., Pro- 
fessor of Anatomy in the Medico- Chirurgical College, Philadelphia. Oc- 
tavo volume of 405 pages, handsomely illustrated. Cloth, $2.50 net. 

HIRST'S OBSTETRICS. 

A Text=Book of Obstetrics. By Barton Cooke Hirst, M. D., 
Professor of Obstetrics in the University of Pennsylvania. Handsome 
octavo volume of 848 pages, with 618 illustrations, and 7 colored 
plates. Cloth, $5.00 net; Sheep or Half Morocco, $6.00 net. 

"The illustrations are numerous and are works of art, many of them appearing for the 
first time. The arrangement of the subject-matter, the foot-notes, and index are beyond 
criticism. As a true model of what a modern text-book on obstetrics should be, we feel 
justified in affirming that Dr. Hirst's book is without a rival." — New York Medical Record. 

HYDE AND MONTGOMERY ON SYPHILIS AND THE VENEREAL 
DISEASES. 
Syphilis and the Venereal Diseases. By James Nevins Hyde, 
M.D., Professor of Skin and Venereal Diseases, and Frank H. Mont- 
gomery, M.D., Lecturer on Dermatology and Genito-Urinary Diseases 
in Rush Medical College, Chicago, 111. 618 pages, profusely illustrated. 
Cloth, $2.50 net. 

" We can commend this manual to the student as a help to him in his study of venereal 
diseases. ' ' — Liverpool Medico- Chirurgical Journal. 

"The best student's manual which has appeared on the subject." — St. Louis Medical 
and Surgical Journal. 



14 Medical Publications of W. B. Saunders. 

JACKSON AND GLEASON'S DISEASES OF THE EYE, NOSE, AND 
THROAT. Second Edition, Revised. 
Essentials of Refraction and Diseases of the Eye. By Edward 
Jackson, A.M., M.D., Professor of Diseases of the Eye in the Phila- 
delphia Polyclinic and College for Graduates in Medicine ; and — 
Essentials of Diseases of the Nose and Throat. By E. Bald- 
win Gleason, M.D., Surgeon-in-Charge of the Nose, Throat, and 
Ear Department of the Northern Dispensary of Philadelphia. Two 
volumes in one. Crown octavo, 290 pages; 124 illustrations. Cloth, 
$1.00; interleaved for notes, $1.25. 

[See Saunders'' Question- Compends, page 21.] 

" Of great value to the beginner in these branches. The authors are both capable men, 
and know what a student most needs." — Medical Record, New York. 

KEATING'S DICTIONARY. Second Edition, Revised. 

A New Pronouncing Dictionary of Medicine, with Phonetic 
Pronunciation, Accentuation, Etymology, etc. By John M. 
Keating, M.D., LL.D., Fellow of the College of Physicians of Phila- 
delphia ; Vice-President of the American Pediatric Society ; Editor 
"Cyclopaedia of the Diseases of Children," etc.; and Henry 
Hamilton, Author of '-'A New Translation of Virgil's ^Eneid into 
English Rhyme," etc.; with the collaboration of J. Chalmers Da- 
Costa, M.D., and Frederick A. Packard, M.D. With an Appendix 
containing Tables of Bacilli, Micrococci, Leucoma'ines, Ptomaines; 
Drugs and Materials used in Antiseptic Surgery ; Poisons and their 
Antidotes ; Weights and Measures ; Thermometric Scales ; New 
Official and Unofficial Drugs, etc. One volume of over 800 pages. 
Prices, with Denison's Patent Ready-Reference Index: Cloth, $5.00 
net; Sheep or Half Morocco, $6.00 net; Half Russia, $6.50 net. 
Without Patent Index: Cloth, $4.00 net; Sheep or Half Morocco, 
$5.00 net. 

" I am much pleased with Keating's Dictionary, and shall take pleasure in recommend- 
ing it to my classes." — Henry M. Lyman, M.D., Professor of the Principles and Practict 
of Medicine, Rush Medical College, Chicago, III. 

" I am convinced that it will be a very valuable adjunct to my study-table, convenient 
in size and sufficiently full for ordinary use." — C. A. LlNDSLEY, M.D., Professor of the 
Theory and Practice of Medicine, Medical Dept. Yale University. 

KEATING'S LIFE INSURANCE. 

How to Examine for Life Insurance. By John M. Keating, 
M. D., Fellow of the College of Physicians of Philadelphia; Vice- 
President of the American Pediatric Society; Ex- President of the 
Association of Life Insurance Medical Directors. Royal octavo, 211 
pages ; with two large half-tone illustrations, and a plate prepared by 
Dr. McClellan from special dissections ; also, numerous other illustra- 
tions. Cloth, $2.00 net. 

" This is by far the most useful book which has yet appeared on insurance examination, 
a subject of growing interest and importance. Not the least valuable portion of the volume 
is Part II., which consists of instructions issued to their examining physicians by twenty-four 
representative companies of this country. If for these alone, the book should be at the right 
hand of every physician interested in this special branch of medical science." — The Medical 
News. 



Medical Publications of W. B. Saunders. 15 

KEEN ON THE SURGERY OF TYPHOID FEVER. 

The Surgical Complications and Sequels of Typhoid Fever. 

By Wm. W. Keen, M.D., LL.D., Professor of the Principles of Sur- 
gery and of Clinical Surgery, Jefferson Medical College, Philadelphia; 
Corresponding Member of the Societe de Chirurgie, Paris; Honorary 
Member of the Societe Beige de Chirurgie, etc. Octavo volume of 
3S6 pages, illustrated. Cloth, $3.00 net. 

" This is probably the first and only work in the English language that gives the reader 
a clear view of what typhoid fever really is, and what it does and can do to the human 
organism. This book should be in the possession of every medical man in America." — 
icon Medico-Surgical Bulletin. 

KEEN'S OPERATION BLANK. Second Edition, Revised Form. 
An Operation Blank, with Lists of Instruments, etc. Required 
in Various Operations. Prepared by W. W. Keen, M.D., LL.D., 
Professor of the Principles of Surgery in Jefferson Medical College, 
Philadelphia. Price per pad, containing blanks for fifty operations, 
50 cents net. 

KYLE ON THE NOSE AND THROAT. 

Diseases of the Nose and Throat. By D. Braden Kyle, M.D., 
Clinical Professor of Laryngology and Rhinology, Jefferson Medical 
College, Philadelphia ; Consulting Laryngologist, Rhinologist, and 
Otologist, St. Agnes' Hospital. Handsome octavo volume of about 
630 pages, with over 150 illustrations and 6 lithographic plates. Price, 
Cloth, $4.00 net; Half Morocco, $5.00 net. 

LAINE'S TEMPERATURE CHART. 

Temperature Chart. Prepared by D. T. Laine, M.D. Size 8 x 13^ 
inches. A conveniently arranged Chart for recording Temperature, 
with columns for daily amounts of Urinary and Fecal Excretions, 
Food, Remarks, etc. On the back of each chart is given in full the 
method of Brand in the treatment of Typhoid Fever. Price, per pad 
of 25 charts, 50 cents net. 

" To the busy practitioner this chart will be found of great value in fever cases, and 
especially for cases of typhoid." — Indian Lancet, Calcutta. 

LOCKWOOD'S PRACTICE OF MEDICINE. 

A Manual of the Practice of Medicine. By George Roe Lock- 
wood, M.D., Professor of Practice in the Woman's Medical College 
of the New York Infirmary, etc. 935 pages, with 75 illustrations in 
the text, and 22 full-page plates. Cloth, $2.50 net. 

" Gives in a most concise manner the points essential to treatment usually enumerated 
in the most elaborate works." — Massachusetts Medical Journal. 

LONGS SYLLABUS OF GYNECOLOGY. 

A Syllabus of Gynecology, arranged in Conformity with " An 
American Text=Book of Gynecology." By J. W. Long, M.D., 
Professor of Diseases of Women and Children, Medical College of 
Virginia, etc. Cloth, interleaved, $1.00 net. 

" The book is certainly an admirable resume of what every gynecological student and 
practitioner should know, and will prove of value not only to those who have the ' American 
Text-Book of Gynecology,' but to others as well." — Brooklyn Medical Journal. 



16 Medical Publications of W. B. Saunders. 

MACDONALD'S SURGICAL DIAGNOSIS AND TREATMENT. 

Surgical Diagnosis and Treatment. By J. W. Macdonald, M.D. 
Edin., F.R. C.S., Edin., Professor of the Practice of Surgery and of 
Clinical Surgery in Hamline University ; Visiting Surgeon to St. 
Barnabas' Hospital, Minneapolis, etc. Handsome octavo volume of 
800 pages, profusely illustrated. Cloth, $5.00 net; Half Morocco, 
$6.00 net. 

" A thorough and complete work on surgical diagnosis and treatment, free from pad- 
ding, full of valuable material, and in accord with the surgical teaching of the day." — The 

Medical News, New York. 

"The work is brimful of just the kind of practical information that is useful alike to 
students and practitioners. It is a pleasure to commend the bock because of its intrinsic 
valuo to the medical practitioner." — Cincinnati Lancet- Clinic , 

MALLORY AND WRIGHTS PATHOLOGICAL TECHNIQUE. 

Pathological Technique. A Practical Manual for Laboratory Work 
in Pathology, Bacteriology, and Morbid Anatomy, with chapters on 
Post-Mortem Technique and the Performance of Autopsies. By Frank 
B. Mallory, A.M., M.D., Assistant Professor of Pathology, Harvarn 
University Medical School, Boston; and James H. Wright, A.M., 
M.D., Instructor in Pathology, Harvard University Medical School, 
Boston. Octavo volume of 396 pages, handsomely illustrated. Cloth, 
$2.50 net. 

" I have been looking forward to the publication of this book, and I am glad to say that 
I find it to be a most useful laboratory and post-mortem guide, full of practical information, 
and well up to date." — Willi AM H. WELCH, Professor of Pathology, Johns Hopkins Uni- 
versity, Baltimore, Md. 

MARTIN'S MINOR SURGERY, BANDAGING, AND VENEREAL 
DISEASES. Second Edition, Revised. 
Essentials of Minor Surgery, Bandaging, and Venereal 
Diseases. By Edward Martin, A.M., M.D., Clinical Professor of 
Genito-Urinary Diseases, University of Pennsylvania, etc. Crown 
octavo, 166 pages, with 78 illustrations. Cloth, $1.00; interleaved for 
notes, $1.25. 

[See Saunders' Question- Compends, page 21.] 

"A very practical and systematic study of the subjects, and shows the author's famil- 
iarity with the needs of students." — Therapeutic Gazette. 

MARTIN'S SURGERY. Sixth Edition, Revised. 

Essentials of Surgery. Containing also Venereal Diseases, Surgi- 
cal Landmarks, Minor and Operative Surgery, and a complete de- 
scription, with illustrations, of the Handkerchief and Roller Bandages. 
By Edward Martin, A.M., M.D., Clinical Professor of Genito- 
Urinary Diseases, University of Pennsylvania, etc. Crown octavo, 338 
pages, illustrated. With an Appendix containing full directions for the 
preparation of the materials used in Antiseptic Surgery, etc. Cloth, 
$1.00;' interleaved for notes, $1.25. 

[See Saunders'' Question- Co?npends , page 21.] 

" Contains all necessary essentials of modern surgery in a comparatively small space. 
Its style is interesting, and its illustrations are admirable." — Medical and Surgical Reporter* 



Medical Publications of W. B. Saunders. 17 

McFARLAND'S PATHOGENIC BACTERIA. Second Edition, Re- 
vised and Greatly Enlarged. 
Text=Book upon the Pathogenic Bacteria. By Joseph McFar- 
land, M. D., Professor of Pathology and Bacteriology in the Medico- 
Chirurgical College of Philadelphia, etc. Octavo volume of 497 pages, 
finely illustrated. Cloth, $2.50 net. 

" Dr. McFarland has treated the subject in a systematic manner, and has succeeded in 
presenting in a concise and readable form the essentials of bacteriology up to date. Alto- 
gether, the book is a satisfactory one, and I shall- take pleasure in recommending it to the 
students of Trinity College." — H. B. Anderson, M.D. , Professor of Pathology and Bac- 
teriology, Trinity Medical College, Toronto. 

MEIGS ON FEEDING IN INFANCY. 

Feeding in Early Infancy. By Arthur V. Meigs, M.D. Bound 
in limp cloth, flush edges, 25 cents net. 

"This pamphlet is worth many times over its price to the physician. The author's 
experiments and conclusions are original, and have been the means of doing much good."— 
Medical Bulletin. 

MOORE'S ORTHOPEDIC SURGERY. 

A Manual of Orthopedic Surgery. By James E. Moore, M.D., 
Professor of Orthopedics and Adjunct Professor of Clinical Surgery, 
University of Minnesota, College of Medicine and Surgery. Octavo 
volume of 356 pages, handsomely illustrated. Cloth, $2.50 net. 

"A most attractive work. The illustrations and the care with which the book is adapted 
to the wants of the general practitioner and the student are worthy of great praise." — Chicago 
Medical Recorder. 

" A very demonstrative work, every illustration of which conveys a lesson. The work is 
a most excellent and commendable one, which we can certainly endorse with pleasure." — 
St. Louis Medical and Surgical Journal. 

MORRIS'S MATERIA MEDICA AND THERAPEUTICS. Fifth 
Edition, Revised. 
Essentials of Materia Medica, Therapeutics, and Prescription" 
Writing. By Henry Morris, M.D., late Demonstrator of Thera- 
peutics, Jefferson Medical College, Philadelphia; Fellow of the College 
of Physicians, Philadelphia, etc. Crown octavo, 288 pages. Cloth, 
#1.00; interleaved for notes, $1.25. 

[See Saunders'' Question- Compends, page 21.] 

" This work, already excellent in the old edition, has been largely improved by revi- 
sion. " — American Practitioner and News. 

MORRIS, WOLFF, AND POWELL'S PRACTICE OF MEDICINE. 
Third Edition, Revised. 
Essentials of the Practice of Medicine. By Henry Morris, M.D., 
late Demonstrator of Therapeutics, Jefferson Medical College, Phila- 
delphia ; with an Appendix on the Clinical and Microscopic Examina- 
tion of Urine, by Lawrence Wolff, M.D., Demonstrator of Chemistry, 
Jefferson Medical College, Philadelphia. Enlarged by some 300 essen- 
tial formulae collected and arranged by William M. Powell, M.D. 
Post-octavo, 488 pages. Cloth, $2.00. 

[See Saunders' Question- Compends, page 21.] 

" The teaching is sound, the presentation graphic ; matter full as can be desired, and 
style attractive." — American Practitioner and News. 
2 



18 Medical Publications of W. B. Saunders. 

MORTEN'S NURSES DICTIONARY. 

Nurse's Dictionary of Medical Terms and Nursing Treat- 
ment. Containing Definitions of the Principal Medical and Nursing 
Terms and Abbreviations ; of the Instruments, Drugs, Diseases, Acci- 
dents, Treatments, Operations, Foods, Appliances, etc. encountered 
in the ward or in the sick-room. By Honnor Morten, author of 
"How to Become a Nurse," etc. i6mo, 140 pages. Cloth, $1.00. 

" A handy, compact little volume, containing a large amount of general information, all 
of which is arranged in dictionary or encyclopedic form, thus facilitating quick reference. 
It is certainly of value to those for whose use it is published." — Chicago Clinical Review. 

NANCREDE'S ANATOMY. Sixth Edition, Thoroughly Revised. 
Essentials of Anatomy, including the Anatomy of the Viscera. 
By Charles B. Nancrede, M.D., LL.D., Professor of Surgery and 
of Clinical Surgery in the University of Michigan, Ann Arbor. Crown 
octavo, 420 pages; 151 illustrations. Based upon Gray's Anatomy. 
Cloth, $1.00 net; interleaved for notes, $1.25 net. 

[See Saunders'' Question- Compends, page 21.] 

"For self-quizzing and keeping fresh in mind the knowledge of anatomy gained at 
school, it would not be easy to speak of it in terms too favorable."— A merican Practitioner. 

NANCREDE'S ANATOMY AND DISSECTION. Fourth Edition. 
Essentials of Anatomy and Manual of Practical Dissection. 

By Charles B. Nancrede, M.D., LL.D., Professor of Surgery and of 
Clinical Surgery, University of Michigan, Ann Arbor. Post-octavo ; 
500 pages, with full-page lithographic plates in colors, and nearly 200 
illustrations. Extra Cloth (or Oilcloth for dissection-room), $2.00 net. 

" It may in many respects be considered an epitome of Gray's popular work on general 
anatomy, at the same time having some distinguishing characteristics of its own to commend 
it. The plates are of more than ordinary excellence, and are of especial value to students 
in their work in the dissecting room." — Journal of the American Medical Association. 

NORRIS'S SYLLABUS OF OBSTETRICS. Third Edition, Revised. 
Syllabus of Obstetrical Lectures in the Medical Department 
of the University of Pennsylvania. By Richard C. Norris, 
A.M., M.D., Demonstrator of Obstetrics, University of Pennsylvania. 
Crown octavo, 222 pages. Cloth, interleaved for notes, $2.00 net. 

" This work is so far superior to others on the same subject that we take pleasure in 
calling attention briefly to its excellent features. It covers the subject thoroughly, and will 
prove invaluable both to the student and the practitioner." — Medical Record, New York. 

PENROSE'S DISEASES OF WOMEN. Second Edition, Revised. 
A Text=Book of Diseases of Women. By Charles B. Penrose, 
M.D., Ph.D., Professor of Gynecology in the University of Pennsyl- 
vania ; Surgeon to the Gynecean Hospital, Philadelphia. Octavo 
volume of 529 pages, handsomely illustrated. Cloth, $3.50 net. 

" I shall value very highly the copy of Penrose's 'Diseases of Women' received. 
I have already recommended it to my class as THE BEST book." — Howard A. Kelly, 
Professor of Gynecology and Obstetrics, Johns Hopkins University , Baltimore, Md. 

" The book is to be commended without reserve, not only to the student but to the 
general practitioner who wishes to have the latest and best modes of treatment explained 
with absolute clearness." — Therapeutic Gazette. 



Medical Publications of W. B. Saunders. 19 

POWELL'S DISEASES OF CHILDREN. Second Edition. 

Essentials of Diseases of Children. By William M. Powell, 
M.D., Attending Physician to the Mercer House for Invalid Women 
at Atlantic City, N. J. ; late Physician to the Clinic for the Diseases of 
Children in the Hospital of the University of Pennsylvania. Crown 
octavo, 222 pages. Cloth, 51.00; interleaved for notes, $1.25. 

[See Saunders'' Questio?i-Compends, page 21.] 

"Contains the gist of all the best works in the department to which it relates."— 
American Practitioner ami News. 

PRINGLE'S SKIN DISEASES AND SYPHILITIC AFFECTIONS. 
Pictorial Atlas of Skin Diseases and Syphilitic Affections 
(American Edition). Translation from the French. Edited by 
J. J. Pringle, M.B,, F.R.C.P., Assistant Physician to the Middlesex 
Hospital, London. Photo-lithochromes from the famous models in 
the Museum of the Saint-Louis Hospital, Paris, with explanatory wood- 
cuts and text. In 12 Parts. Price per Part, $3.00. Complete in 
one volume, Half Morocco binding, $40.00 net. 

" I strongly recommend this Atlas. The plates are exceedingly well executed, and 
will be of great value to all studying dermatology." — Stephen Mackenzie, M.D. 

" The introduction of explanatory wood-cuts in the text is a novel and most important 
feature which greatly furthers the easier understanding of the excellent plates, than which 
nothing, we venture to say, has been seen better in point of correctness, beauty, and general 
merit." — New York Medical Journal. 

PRYOR— PELVIC INFLAMMATIONS. 

The Treatment of Pelvic Inflammations through the Vagina. 

By W. R. Pryor, M.D., s Professor of Gynecology in New York Poly- 
clinic, nmo, 248 pages, handsomely illustrated. Cloth, $2.00 net. 

" This subject, which has recently been so thoroughly canvassed in high gynecological 
circles, is made available in this volume to the general practitioner and student. Nothing is 
too minute for mention and nothing is taken for granted ; consequently the book is of the utmost 
value. The illustrations and the technique are beyond criticism." — Chicago Medical Recorder. 

PYE'S BANDAGING. 

Elementary Bandaging and Surgical Dressing. With Direc- 
tions concerning the Immediate Treatment of Cases of Emergency. 
For the use of Dressers and Nurses. By Walter Pye, F.R.C.S., late 
Surgeon to St. Mary's Hospital, London. Small i2mo, with over 80 
illustrations. Cloth, flexible covers, 75 cents net. 
"The directions are clear and the illustrations are good." — London Lancet. 
"The author writes well, the diagrams are clear, and the book itself is small and port- 
able, although the paper and type are good." — British Medical Journal. 

RAYMOND'S PHYSIOLOGY. 

A Manual of Physiolugy. By Joseph H. Raymond, A.M., M.D., 
Professor of Physiology and Hygiene and Lecturer on Gynecology in 
the Long Island College Hospital; Director of Physiology in the 
Hoagland Laboratory, etc. 382 pages, with 102 illustrations in the 
text, and 4 full-page colored plates. Cloth, $1.25 net. 

" Extremely well gotten up, and the illustrations have been selected with care. The 
text is fully abreast with modern physiology. "—British Medical Journal. 




Saunders* 

Q 



Arranged in Question and 
Answer Form. 

\JI2iO 1 LkJ±\ qpHE MOST COMPLETE AND BEST 

^OI^TTPThNTT^C illustrated series of 

V^vJlVJJrlllN DO COMPENDS EVER ISSUED. 

Now the Standard Authorities in Medical Literature 

with Students and Practitioners in every City of the United States and Canada* 



^ OVER 175,000 COPIES SOLD* ^ 
THE REASON WHY* 

They are the advance guard of "Student's Helps" — that do help. They are the 
leaders in their special line, well and authoritatively written by able men, who, as teachers in 
the large colleges, know exactly what is wanted by a student preparing for his examinations. 
The judgment exercised in the selection of authors is fully demonstrated by their professional 
standing. Chosen from the ranks of Demonstrators, Quiz-masters, and Assistants, most of 
them have become Professors and Lecturers in their respective colleges. 

Each book is of convenient size (5x7 inches) , containing on an average 250 pages, 
profusely illustrated, and elegantly printed in clear, readable type, on fine paper. 

The entire series, numbering twenty-three volumes, has been kept thoroughly revised 
and enlarged when necessary, many of the books being in their fifth and sixth editions. 

TO SUM UP* 

Although there are numerous other Quizzes, Manuals, Aids, etc. in the market, none of 
them approach the "Blue Series of Question Compends;" and the claim is made for the 
following points of excellence : 

1. Professional distinction and reputation of authors. 

2. Conciseness, clearness, and soundness of treatment. 

3. Quality of illustrations, paper, printing, and binding. 

Any cf these Compends will be mailed on receipt of price (see next page for List). 



Oaunders' Question-Compend Series, 

Price, Cloth, $1.00 per copy, except when otherwise noted. 



"Where the work of preparing students' manuals is to end we cannot say, but the 
Saunders Series, in our opinion, bears off the palm at present."— New York Medical Record. 



1. ESSENTIALS OF PHYSIOLOGY. By H. A. Hare, M.D. Fourth edition, 

revised and enlarged. ($1.00 net.) 

2. ESSENTIALS OF SURGERY. By Edward Martin, M.D. Sixth edition, 

revised, with an Appendix on Antiseptic Surgery. 

3. ESSENTIALS OF ANATOMY. By Chari.es B. Nancrede, M.D. Sixth 

edition, thoroughly revised and enlarged. ($i.oo net.) 

4. ESSENTIALS OF MEDICAL CHEMISTRY, ORGANIC AND INORGANIC. 

By Lawrence Wolff, M.D. Fifth edition, revised. ($i.oo net.) 

5. ESSENTIALS OF OBSTETRICS. By W. Easterly Ashton, M.D. Fourth 

edition, revised and enlarged. 

6. ESSENTIALS OF PATHOLOGY AND MORBID ANATOMY. By C. E. 

Armand Semple, M.D. 

7. ESSENTIALS OF MATERIA MEDICA, THERAPEUTICS, AND PRE- 

SCRIPTION=WRITING. By Henry Morris, M.D. Fifth edition, revised. 

8. 9. ESSENTIALS OF PRACTICE OF MEDICINE. By Henry Morris, 

M.D. An Appendix on Urine Examination. By Lawrence Wolff, M.D. 
Third edition, enlarged by some 300 Essential Formulae, selected from eminent 
authorities, by Wm. M. Powell, M.D. (Double number, $2.00.) 

10. ESSENTIALS OF GYNAECOLOGY. By Edwin B. Cragin, M.D. Fourth 

edition, revised. 

11. ESSENTIALS OF DISEASES OF THE SKIN. By Henry W. Stelwagon, 

M.D. Fourth edition, revised and enlarged. ($1.00 net.) 

12. ESSENTIALS OF MINOR SURGERY, BANDAGiNG, AND VENEREAL 

DISEASES. By Edward Martin, M.D. Second ed., revised and enlarged. 

13. ESSENTIALS OF LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE. 

By C. E. Armand Semple, M.D. 

14. ESSENTIALS OF DISEASES OF THE EYE, NOSE, AND THROAT. 

By Edward Jackson, M.D., and E. B. Gleason, M.D. Second ed., revised. 

15. ESSENTIALS OF DISEASES OF CHILDREN. By William M. Powell, 

M.D. Second edition. 

16. ESSENTIALS OF EXAMINATION OF URINE. By Lawrence Wolff, 

M.D. Colored "Vogel Scale." (75 cents.) 

17. ESSENTIALS OF DIAGNOSIS. By S. Solis Cohen, M.D., and A. A. Eshner, 

M.D. ($1.50 net.) 

18. ESSENTIALS OF PRACTICE OF PHARMACY. By Lucius E. Sayre. 

Second edition, revised and enlarged. 

20. ESSENTIALS OF BACTERIOLOGY. By M. V. Ball, M.D. Third edition, 

revised. 

21. ESSENTIALS OF NERVOUS DISEASES AND INSANITY. By John C. 

Shaw, M.D. Third edition, revised. 

22. ESSENTIALS OF MEDICAL PHYSICS. By Fred J. Brockway, M.D. 

Second edition, revised. ($1.00 net.) 

23. ESSENTIALS OF MEDICAL ELECTRICITY. By David D. Stewart, M.D., 

and Edward S. Lawrance, M.D. 

24. ESSENTIALS OF DISEASES OF THE EAR. By E. B. Gleason, M.D. 

Second edition, revised and greatly enlarged. 



Pamphlet containing specimen pages, etc. sent free upon application. 







Saunders' , e , 

tor Students 



New Series and 

of Manua 



|« Practitioners, 



^T'HAT there exists a need for thoroughly reliable hand-books on the leading branches 
of Medicine and Surgery is a fact amply demonstrated by the favor with which 
the SAUNDERS NEW SERIES OF MANUALS have been received by medical 
students and practitioners and by the Medical Press, These manuals are not merely 
condensations from present literature, but are ably written by well-known authors 
and practitioners, most of them being teachers in representative American colleges. 
Each volume is concisely and authoritatively written and exhaustive in detail, without 
being encumbered with the introduction of "cases," which so largely expand the 
ordinary text-book. These manuals will therefore form an admirable collection of 
advanced lectures, useful alike to the medical student and the practitioner: to the 
latter, too busy to search through page after page of elaborate treatises for what he 
wants to know, they will prove of inestimable value ; to the former they will afford 
safe guides to the essential points of study. 

The SAUNDERS NEW SERIES OF MANUALS are conceded to be superior 
to any similar books now on the market. No other manuals afford so much infor- 
mation in such a concise and available form. A liberal expenditure has enabled the 
publisher to render the mechanical portion of the work worthy of the high literary 
standard attained by these books. 

Any of these Manuals will be mailed on receipt of price (see next page for List). 



Saunders' New Series of Manuals* 



VOLUMES PUBLISHED. 

PHYSIOLOGY. By JOSEPH Howard Raymond, A.M., M.D., Professor of Physiology 
and Hygiene and Lecturer on Gynecology in the Long Island College Hospital; 
Director of Physiology in the Hoagland Laboratory, etc. Illustrated. Cloth, $1.25 net. 

SURGERY, General and Operative. Py John Chalmers DaCosta, M.D., Clini- 
cal Professor of Surgery, Jefferson Medical College, Philadelphia; Surgeon to the 
Philadelphia Hospital, etc. Second edition, thoroughly revised and greatly enlarged. 
Octavo, 911 pages, profusely illustrated. Cloth, $4.00 net ; Half Morocco, $5.00 net. 

DOSE=BOOK AND MANUAL OF PRESCRIPTION=WRITING. By E Q. 

Thornton, M.D., Demonstrator of Therapeutics, Jefferson Medical College, Phila- 
delphia. Illustrated. Cloth, Si. 25 net. 

SURGICAL ASEPSIS. By Carl Beck, M.D., Surgeon to St. Mark's Hospital and 
to the New York German Poliklinik, etc. Illustrated. Cloth, $1.25 net. 

MEDICAL JURISPRUDENCE. By Henry C. Chapman, M.D. Professor of Insti- 
tutes of Medicine and Medical Jurisprudence in the Jefferson Medical College of Phila- 
delphia. Illustrated. Cloth, Si. 50 net. 

SYPHILIS AND THE VENEREAL DISEASES. By James Nevins Hyde, M.D., 
Professor of Skin and Venereal Diseases, and Frank H. Montgomery, M.D., 
Lecturer on Dermatology and Genito-Urinary Diseases in Rush Medical College, 
Chicago. Profusely illustrated. Cloth, $2.50 net. 

PRACTICE OF MEDICINE. By George Roe Lockwood, M.D., Professor of 
Practice in the Woman's Medical College of the New York Infirmary ; Instructor in 
Physical Diagnosis in the Medical Department of Columbia College, etc. Illustrated. 
Cloth, $2.50 net. 

MANUAL OF ANATOMY. By Irving S. Haynes, M.D., Adjunct Professor of 
Anatomy and Demonstrator of Anatomy, Medical Department of the New York 
University, etc. Beautifully illustrated. Cloth, $2.50 net. 

MANUAL OF OBSTETRICS. By W. A. Newman Dorland, M.D., Assistant 
Demonstrator of Obstetrics, University of Pennsylvania ; Chief of Gynecological Dis- 
pensary, Pennsylvania Hospital, etc. Profusely illustrated. Cloth, $2.50 net. 

DISEASES OF WOMEN. By J. Bland Sutton, F. R. C. S., Assistant Surgeon to 
Middlesex Hospital and Surgeon to Chelsea Hospital, London; and Arthur E. 
Giles, M. D., B. Sc. Lond., F.R.C.S. Edin., Assistant Surgeon to Chelsea Hospital, 
London. Handsomely illustrated. Cloth, £2.50 net. 



VOLUMES IN PREPARATION. 

NERVOUS DISEASES. By Charles W. Burr, M.D., Clinical Professor of Nervous 
Diseases, Medico-Chirurgical College, Philadelphia ; Pathologist to the Orthopaedic 
Hospital and Infirmary for Nervous Diseases ; Visiting Physician to the St. Joseph 
Hospital, etc. 

*** There will be published in the same series, at short intervals, carefully-prepared works 
on various subjects by prominent specialists. 



Pamphlet containing specimen pages, etc. sent free upon application. 



24 Medical Publications of W. B. Saunders. 

SAUNDBY'S RENAL AND URINARY DISEASES. 

Lectures on Renal and Urinary Diseases. By Robert Saundby, 
M.D. Edin., Fellow of the Royal College of Physicians, London, and 
of the Royal Medico-Chirurgical Society ; Physician to the General 
Hospital ; Consulting Physician to the Eye Hospitai and to the Hos- 
pital for Diseases of Women; Professor of Medicine in Mason College, 
Birmingham, etc. Octavo volume of 434 pages, with numerous illus- 
trations and 4 colored plates. Cloth, $2.50 net. 

" The volume makes a favorable impression at once. The style is clear and succinct. 
We cannot find any part of the subject in which the views expressed are not carefully thought 
out and fortified by evidence drawn from the most recent sources. The book may be cordially 
recommended." — British Medical Journal. 

5AUNDERS' MEDICAL HAND=ATLA5E5. 

This series of books consists of authorized translations into English of 
the world-famous Lehmann Medicinische Handatlanten. Each 
volume contains from 50 to 100 colored lithographic plates, besides 
numerous illustrations in the text. There is a full description of each- 
plate, and each book contains a condensed but adequate outline of the 
subject to which it is devoted. For full description of this series, with 
list of volumes and prices, see page 2. 

" Lehmann Medicinische Handatlanten belong to that class of books that are too good 
to be appropriated by any one nation." — "Journal of Eye, Ear, and Throat Diseases. 

" The appearance of these works marks a new era in illustrated English medical 
works." — The Canadian Practitioner. 

SAUNDERS' POCKET MEDICAL FORMULARY. Fifth Edition, 
Revised. 

By William M. Powell, M.D., Attending Physician to the Mercer 
House for Invalid Women at Atlantic City, N. J. Containing 1800 
formulae selected from the best-known authorities. With an Appen- 
dix containing Posological Table, Formulae and Doses for Hypo- 
dermic Medication, Poisons and their Antidotes, Diameters of the 
Female Pelvis and Fcetal Head, Obstetrical Table, Diet List for Various 
Diseases, Materials and Drugs used in Antiseptic Surgery, Treatment 
of Asphyxia from Drowning, Surgical Remembrancer, Tables of 
Incompatibles, Eruptive Fevers, Weights and Measures, etc. Hand- 
somely bound in flexible morocco, with side index, wallet, and flap, 
I1.75 net. 

"This little book, that can be conveniently carried in the pocket, contains an immense 
amount of material. It is very useful, and, as the name of the author of each prescription 
is given, is unusually reliable." — Medical Record, New York. 

SAYRE'S PHARMACY. Second Edition, Revised. 

Essentials of the Practice of Pharmacy. By Lucius E. Sayre, 
M.D., Professor of Pharmacy and Materia Medica in the University of 
Kansas. Crown octavo, 200 pages. Cloth, $1.00; interleaved for 
notes, $1.25. 

[See Saunders'' Question- Compends, page 21.] 

" The topics are treated in a simple, practical manner, and the work forms a very useful 
student's manual." — Boston Medical and Surgical Journal. 



Medical Publications of W. B. Saunders. 25 

SEMPLE'S LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE. 
Essentials of Legal Medicine, Toxicology, and Hygiene. By 
C. E. Armand Semple, B. A., M. B. Cantab., M. R. C. P. Lond., 
Physician to the Northeastern Hospital for Children, Hackney, etc. 
Crown octavo, 212 pages; 130 illustrations. Cloth, $1. 00; interleaved 
for notes, ^1.25. 

[See Saunders Question- Co?npends, page 21.] 

" No general practitioner or student can afford to be without this valuable work. The 
subjects are dealt with by a masterly hand." — London Hospital Gazette. 

SEMPLE'S PATHOLOGY AND MORBID ANATOMY. 

Essentials of Pathology and Morbid Anatomy. By C. E. 

Armand Semple, B.A., M.B. Cantab., M.R.C.P. Lond., Physician to 
the Northeastern Hospital for Children, Hackney, etc. Crown octavo, 
174 pages; illustrated. Cloth, $1.00; interleaved for notes, $1.25. 
[See Saunders' Question- Conipends, page 21.] 

" Should take its place among the standard volumes on the bookshelf of both student 
and practitioner." — London Hospital Gazette. 

SENN'S GENITOURINARY TUBERCULOSIS. 

Tuberculosis of the Genito=Urinary Organs, Male and Female. 

By Nicholas Senn, M.D., Ph.D., LL.D., Professor of the Practice of 
Surgery and of Clinical Surgery, Rush Medical College, Chicago. 
Handsome octavo volume of 320 pages, illustrated. Cloth, $3.00 net. 

" An important book upon an important subject, and written by a man of mature judg- 
ment and wide experience. The author has given us an instructive book upon one of the 
most important subjects of the day." — Clinical Reporter. 

" A work which adds another to the many obligations the profession owes the talented 
author." — Chicago Medical Recorder. 

SENN'S SYLLABUS OF SURGERY. 

A Syllabus of Lectures on the Practice of Surgery, arranged 
in conformity with " An American Text=Book of Surgery. " By 

Nicholas Senn, M.D., Ph.D., Professor of the Practice of Surgery and 
of Clinical Surgery in Rush Medical College, Chicago. Cloth, $2.00. 

" This syllabus will be found of service by the teacher as well as the student, the work 
being superbly done. There is no praise too high for it. No surgeon should be without 
it." — New York Medical Times. 

SENN'S TUMORS. 

Pathology and Surgical Treatment of Tumors. By N. Senn, 
M.D., Ph.D., LL.D., Professor of Surgery and of Clinical Surgery, 
Rush Medical College ; Professor of Surgery, Chicago Polyclinic ; 
Attending Surgeon to Presbyterian Hospital ; Surgeon-in-Chief, St. 
Joseph's Hospital, Chicago. Octavo volume of 710 pages, with 515 
engravings, including full-page colored plates. New and Revised Edi- 
tion in Preparation. 

" The most exhaustive of any recent book in English on this subject. It is well illus- 
trated, and will doubtless remain as the principal monograph on the subject in our language 
for some years. The book is handsomely illustrated and printed, and the author has given a 
notable and lasting contribution to surgery." — Journal of the American Medical Association. 



26 Medical Publications of W. B. Saunders. 

SHAW'S NERVOUS DISEASES AND INSANITY. Third Edition, 
Revised. 
Essentials of Nervous Diseases and Insanity. By John C. 
Shaw, M.D., Clinical Professor of Diseases of the Mind and Nervous 
System, Long Island College Hospital Medical School ; Consulting 
Neurologist to St. Catherine's Hospital and to the Long Island College 
Hospital. Crown octavo, 186 pages; 48 original illustrations. Cloth, 
#1.00 ; interleaved for notes, $1.25. 

[See Saunders' Question- Compends, page 21.] 
"Clearly and intelligently written. ; ' — Boston Medical and Surgical Journal. 

"There. is a mass of valuable material crowded into this small compass." — American 
Medico- Surgical Bulletin. 

STARR'S DIETS FOR INFANTS AND CHILDREN. 

Diets for Infants and Children in Health and in Disease. By 

Louis Starr, M.D., Editor of "An American Text-Book of the 
Diseases of Children." 230 blanks (pocket-book size), perforated 
and neatly bound in flexible morocco. $1.25 net. 

The first series of blanks are prepared for the first seven months of infant life ; each 
blank indicates the ingredients, but not the quantities, of the food, the latter directions being 
left for the physician. After the seventh month, modifications being less necessary, the diet 
lists are printed in full. Formulae for the preparation of diluents and foods are appended. 

STELW AGON'S DISEASES OF THE SKIN. Fourth Ed., Revised. 
Essentials of Diseases of the Skin. By Henry W. Stelwagon, 
M.D., Clinical Professor of Dermatology in the Jefferson Medical 
College, Philadelphia ; Dermatologist to the Philadelphia Hospital ; 
Physician to the Skin Department of the Howard Hospital, etc. 
Crown octavo, 276 pages; 88 illustrations. Cloth, $1. 00 net; inter- 
leaved for notes, $1.25 net. 

[See Saunders'' Question- Compends, page 21.] 
" The best student's manual on skin diseases we have yet seen." — Times and Register. 

STENGEL'S PATHOLOGY. Second Edition. 

A Text=Book of Pathology. By Alfred Stengel, M.D., Professor 
of Clinical Medicine in the University of Pennsylvania ; Physician to 
the Philadelphia Hospital ; Physician to the Children's Hospital, etc. 
Handsome octavo volume of 848 pages, with nearly 400 illustrations, 
many of them in colors. Cloth, $4.00 net; Half Morocco, $5.00 
net. 

STEVENS' MATERIA MEDICA AND THERAPEUTICS. Second 
Edition, Revised. 
A Manual of Materia Medica and Therapeutics. By A. A. 

Stevens, A.M., M.D., Lecturer on Terminology and Instructor in 
Physical Diagnosis in the University of Pennsylvania; Professor of 
Pathology in the Woman's Medical College of Pennsylvania. Post- 
octavo, 445 pages. Flexible leather, $2.25. 
"The author has faithfully presented modern therapeutics in a comprehensive work, 
and, while intended particularly for the use of students, it will be found a reliable guide and 
sufficiently comprehensive for the physician in practice." — University Medical Magazine. 



Medical Publications of W. B. Saunders. 27 

STEVENS' PRACTICE OF MEDICINE. Fifth Edition, Revised. 
A Manual of the Practice of Medicine. By A. A. Stevens, A. M., 
M. D., Lecturer on Terminology and Instructor in Physical Diagnosis 
in the University of Pennsylvania; Professor of Pathology in the 
Woman's Medical College of Pennsylvania. Specially intended for 
students preparing for graduation and hospital examinations. Post- 
octavo, 519 pages; illustrated. Flexible leather, $2.00 net. 

" The frequency with which new editions of this manual are demanded bespeaks its 
popularity. It is an excellent condensation of the essentials of medical practice for the 
student, and maybe found also an excellent reminder for the busy physician." — Buffalo 
Medical Journal '. 

STEWART'S PHYSIOLOGY. Third Edition, Revised. 

A Manual of Physiology, with Practical Exercises. For 
Students and Practitioners. By G. N. Stewart, M.A., M.D., 
D.Sc, lately Examiner in Physiology, University of Aberdeen, and 
of the New Museums, Cambridge University ; Professor of Physiology 
in the Western Reserve University, Cleveland, Ohio. Octavo volume 
of 848 pages ; 300 illustrations in the text, and 5 colored plates. 
Cloth, $3.75 net. 

" It will make its way by sheer force of merit, and amply deserves to do so. It is one 
of the very best English tekt-books on the subject." — London Lancet. 

"Of the many text-books of physiology published, we do not know of one that so 
nearly comes up to the ideal as does Prof. Stewart's volume."- — British Medical Journal. 

STEWART AND LAWRANCE'S MEDICAL ELECTRICITY. 

Essentials of Medical Electricity. By D. D. Stewart, M.D., 
Demonstrator of Diseases of the Nervous System and Chief of the 
Neurological Clinic in the Jefferson Medical College; and E. S. 
Lawrance, M.D., Chief of the Electrical Clinic and Assistant Demon- 
strator of Diseases of the Nervous System in the Jefferson Medical 
College, etc. Crown octavo, 158 pages; 65 illustrations. Cloth, 
$1.00; interleaved for notes, $1.25. 

[See Saunders' Question- Comp ends, page 21.] 

" Throughout the whole brief space at their command the authors show a discriminating 
knowledge of their subject." — Medical News. 

STONEY'S NURSING. Second Edition, Revised. 

Practical Points in Nursing. For Nurses in Private Practice, 

By Emily A. M. Stoney, Graduate of the Training-School for Nurses, 
Lawrence, Mass.; late Superintendent of the Training-School for 
Nurses, Carney Hospital, South Boston, Mass. 456 pages, illustrated 
with 73 engravings in the text, and 8 colored and half-tone plates. 
Cloth, $1.75 net. 

"There are few books intended for non-professional readers which can be so cordially 
endorsed by a medical journal as can this one." — Therapeutic Gazette. 

" This is a well-written, eminently practical volume, which covers the entire range of 
private nursing as distinguished from hospital nursing, and instructs the nurse how best to 
meet the various emergencies which may arise, and how to prepare everything ordinarily 
needed in the illness of her patient." — American Journal of Obstetrics and Diseases of 
Women and Children. 

" It is a work that the physician can place in the hands of his private nurses with the 
assurance of benefit." — Ohio Medical Journal. 



28 Medical Publications of W. B. Saunders. 

STONEY'S MATERIA MEDICA FOR NURSES. 

Materia Medica for Nurses. By Emily A. M. Stoney, Graduate of 
the Training-School for Nurses, Lawrence, Mass. ; late Superintendent 
of the Training-School for Nurses, Carney Hospital, South Boston, Mass. 
Handsome octavo volume of 306 pages. Cloth, $1.50 net. 

The present book differs from other similar works in several features, all of which are 
intended to render it more practical and generally useful. The general plan of the contents 
follows the lines laid down in training-schools for nurses, but the book contains much use- 
ful matter not usually included in works of this character, such as Poison-emergencies, 
Ready Dose-list, Weights and Measures, etc., as well as a Glossary, defining all the terms 
used in Materia Medica, and describing all the latest drugs and remedies, which have been 
generally neglected by other books of the kind. 

SUTTON AND GILES' DISEASES OF WOMEN. 

Diseases of Women. By J. Bland Sutton, F.R.C.S., Assistant 
Surgeon to Middlesex Hospital, and Surgeon to Chelsea Hospital, 
London; and Arthur E. Giles, M.D., B.Sc. Lond. , F.R.C.S. Edin., 
Assistant Surgeon to Chelsea Hospital, London. 436 pages, hand- 
somely illustrated. Cloth, $2.50 net. 

"The text has been carefully prepared. Nothing essential has been omitted, and its 
teachings are those recommended by the leading authorities of the day." — Journal of the 
American Aledical Association. 

THOMAS'S DIET LISTS AND SICK=ROOM DIETARY. 

Diet Lists and Sick=Room Dietary. By Jerome B. Thomas, 
M.D., Visiting Physician to the Home for Friendless Women and 
Children and to the Newsboys' Home ; Assistant Visiting Physician 
to the Kings County Hospital. Cloth, $1.50. Send for sample sheet. 

THORNTON'S DOSE=BOOK AND PRESCRIPTION=WRITING. 

Dose=Book and Manual of Prescription=Writing. By E. Q. 

Thornton, M.D., Demonstrator of Therapeutics, Jefferson Medical 
College, Philadelphia. 334 pages, illustrated. Cloth, $1.25 net. 

"Full of practical suggestions; will take its place in the front rank of works of this 
sort." — Medical Record, New York. 

VAN VALZAH AND NISBET'S DISEASES OF THE STOMACH. 
Diseases of the Stomach. By William W. Van Valzah, M.D., 
Professor of General Medicine and Diseases of the Digestive System 
and the Blood, New York Polyclinic; and J. Douglas Nisbet, M.D., 
Adjunct Professor of General Medicine and Diseases of the Digestive 
System and the Blood, New York Polyclinic. Octavo volume of 674 
pages, illustrated. Cloth, $3.50 net. 

" Its chief claim lies in its clearness and general adaptability to the practical needs of 
the general practitioner or student. In these relations it is probably the best of the recent 
special works on diseases of the stomach." — Chicago Clinical Review. 

VECKI'S SEXUAL IMPOTENCE. 

The Pathology and Treatment of Sexual Impotence. By Victor 
G. Vecki, M.D. From the second German edition, revised and en- 
larged. Demi-octavo, about 300 pages. Cloth, $2.00 net. 

The subject of impotence has seldom been treated in this country in the truly scientific 
spirit that it deserves. Dr. Vecki's work has long been favorably known, and the German 
book has received the highest consideration. This edition is more than a mere translation, 
for, although based on the German edition, it has been entirely rewritten in English. 



Medical Publications of W. B. Saunders. 29 

VIERORDT'S MEDICAL DIAGNOSIS. Fourth Edition, Revised. 
Medical Diagnosis. By Dr. Oswald Vierordt, Professor of Medi- 
cine at the University of Heidelberg. Translated, with additions, 
from the fifth enlarged German edition, with the author's permission, 
by Francis H. Stuart, A. M., M. D. Handsome royal octavo volume 
of 603 pages; 194 fine wood-cuts in text, many of them in colors. 
Cloth. 54.00 net; Sheep or Half Morocco, $5.00 net. 

" A treasury of practical information which will be found of daily use to every busy 
practitioner who will consult it." — C. A. LlNDSLEY, M.D., Professor of the Theory and 
Practice of Medicine \ Yale University. 

" Rarely is a book published with which a reviewer can find so little fault as with the 
volume before us. Each particular item in the consideration of an organ or apparatus, which 
is necessary to determine a diagnosis of any disease of that organ, is mentioned ; nothing 
seems forgotten. The chapters on diseases of the circulatory and digestive apparatus and 
nervous system are especially full and valuable. The reviewer would repeat that the book is 
one of the best — probably the best — which has fallen into his hands." — University Medical 
Magazine. 

WARREN'S SURGICAL PATHOLOGY AND THERAPEUTICS. 

Surgical Pathology and Therapeutics. By John Collins Warren, 
M.D., LL.D., Professor of Surgery, Medical Department Harvard 
University; Surgeon to the Massachusetts General Hospital, etc. 
Handsome octavo volume of 832 pages; 136 relief and lithographic 
illustrations, 33 of which are printed in colors, and all of which were 
drawn by William J. Kaula from original specimens. Revised and 
Enlarged Edition in Preparation. 

"There is the work of Dr. "Warren, which I think is the most creditable book on 
Surgical Pathology, and the most beautiful medical illustration of the bookmaker's art, that 
has ever been issued from the American press." — Dr. Roswell Park, in the Harvard 
Graduate Magazine. 

" The handsomest specimen of bookmaking that has ever been issued from the American 
medical press." — American Journal of the Medical Sciences. 

" A most striking and very excellent feature of this book is its illustrations. Without 
exception, from the point of accuracy and artistic merit, they are the best ever seen in a work 
of this kind. Many of those representing microscopic pictures are so perfect in their coloring 
and detail as almost to give the beholder the impression that he is looking down the barrel 
of a microscope at a well-mounted section." — Annals of Surgery. 

WOLFF ON EXAMINATION OF URINE. 

Essentials of Examination of Urine. By Lawrence Wolff, M.D., 
Demonstrator of Chemistry, Jefferson Medical College, Philadelphia, 
etc. Colored (Vogel) urine scale and numerous illustrations. Crown 
octavo. Cloth, 75 cents. 

[See Saunders 1 Question- Compends, page 21.] 
" A very good work of its kind — very well suited to its purpose." — Times and Register. 

WOLFF'S MEDICAL CHEMISTRY. Fifth Edition, Revised. 

Essentials of Medical Chemistry, Organic and Inorganic. 

Containing also Questions on Medical Physics, Chemical Physiology, 
Analytical Processes, Urinalysis, and Toxicology. By Lawrence 
Wolff, M.D., Demonstrator of Chemistry, Jefferson Medical College, 
Philadelphia, etc. Crown octavo, 222 pages. Cloth, $1.00 net; inter- 
leaved for notes, $1.25 net. 

[See Saunders' Question- Compends, page 21.] 

"The scope of this work is certainly equal to that of the best course of lectures on 
Medical Chemistry." — Pharmaceutical Era. 



CLASSIFIED LIST 



3V\££ 



Medical Publications '*\ 



W. B, SAUNDERS, 

925 Walnut Street, Philadelphia, 



ANATOMY, EMBRYOLOGY, 
HISTOLOGY. 

Clarkson — A Text-Book of Histology, 9 

Haynes — A Manual of Anatomy, ... 13 

Heisler — A Text- Book of Embryology, 1 3 

Nancrede — Essentials of Anatomy, . . 18 
Nancrede — Essentials of Anatomy and 

Manual of Practical Dissection, ... 18 
Semple — Essentials of Pathology and 

Morbid Anatomy, 25 

BACTERIOLOGY. 

Ball — Essentials of Bacteriology, ... 6 
Crookshank — A Text- Book of Bacteri- 
ology, 10 

Frothingham — Laboratory Guide, . . II 
Mallory and Wright — Pathological 

Technique, 16 

McFarland — Pathogenic Bacteria, . . 17 

CHARTS, DIET=LISTS, ETC. 

Griffith— Infant's Weight Chart, ... 12 

Hart — Diet in Sickness and in Health, . 13 

Keen — Operation Blank, 15 

Laine — Temperature Chart, 15 

Meigs — Feeding in Early Infancy, . . 17 

Starr — Diets for Infants and Children, . 26 
Thomas — Diet-Lists and Sick-Room 

Dietary, • 28 

CHEMISTRY AND PHYSICS. 

Brockway — Essentials of Medical Phys- 
ics, 7 

Wolff — Essentials of Medical Chemistry, 29 

CHILDREN. 

An American Text-Book of Diseases 

of Children, . 3 

Griffith — Care of the Baby, 12 

Griffith — Infant's Weight Chart, ... 12 

Meigs — Feeding in Early Infancy, . . 17 

Powell — Essentials of Dis. of Children, 19 

Starr — Diets for Infants and Children, . 26 

DIAGNOSIS. 

Cohen and Eshner— Essentials of Di- 
agnosis, . 9 

Corwin — Physical Diagnosis, .... 9 

Macdonald — Surgical Diagnosis and 

Treatment, 16 

Vierordt — Medical Diagnosis, .... 29 

DICTIONARIES. 

Dorland — Pocket Dictionary, . . . . 10 

Keating — Pronouncing Dictionary, . . 14 

Morten — Nurse's Dictionary, .... 18 



EYE, EAR, NOSE, AND THROAT. 

An American Text- Book of Diseases 

of the Eye, Ear, Nose, and Throat, . 3 
De Schweinitz — Diseases of the Eye, . 10 
Gleason — Essentials of Dis. of the Ear, 11 
Jackson— Manual of Diseases of Eye, . 32 
Jackson and Gleason — Essentials of 

Diseases of the Eye, Nose, and Throat, 14 
Kyle — Diseases of the Nose and Throat, 15 

GENITOURINARY. 

An American Text-Book of Genito- 
urinary and Skin Diseases, 4 

Hyde and Montgomery — Syphilis and 
the Venereal Diseases, ....... 13 

Martin — Essentials of Minor Surgery, 

Bandaging, and Venereal Diseases, . 16 
Saundby — Renal and Urinary Diseases, 24 
Senn — Genito-Urinary Tuberculosis, . 25 
Vecki — Sexual Impotence, 28 

GYNECOLOGY. 

American Text- Book of Gynecology, 4 
Cragin — Essentials of Gynecology, 
Garrigues — Diseases of Women, . 
Long — Syllabus of Gynecology, . 
Penrose — Diseases of Women, . . 
Pryor — Pelvic Inflammations, 



9 
II 

15 
18 
32 
Sutton and Giles — Diseases of Women, 28 

MATERIA MEDICA, PHARMACOL- 
OGY, AND THERAPEUTICS. 

An American Text-Book of Applied 

Therapeutics, . , 3 

Butler — Text-Book of Materia Medica, 

Therapeutics and Pharmacology, ... 8 
Cerna — Notes on the Newer Remedies, 8 
Griffin — Materia Med. and Therapeutics, 12 
Morris — Essentials of Materia Medica 

and Therapeutics, 17 

Saunders' Pocket Medical Formulary, 24 
Sayre — Essentials of Pharmacy, ... 24 
Stevens — Essentials of Materia Medica 

and Therapeutics, 26 

Stoney — Materia Medica for Nurses, . . 28 
Thornton — Dose- Book and Manual of 

Prescription-Writing, 28 

MEDICAL JURISPRUDENCE AND 
TOXICOLOGY. 

Chapman — Medical Jurisprudence and 
Toxicology, .... .... 8 

Semple — Essentials of Legal Medicine, 
Toxicology, and Hygiene, 25 



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